701457374

230509

[MedRec]

  • 2023-04-27 ~ 2023-05-08 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • Nasopharynx MRI showed squamous cell carcinoma of right tongue and floor of mouth with lymph node metastasis cT4bN3bM0 stage IVb.
      • His treatment plans were palliative chemotherapy followed by salvage surgeries.
      • lntraoral wound change dressing qd. Oral intake with clear liquid diet because of patient refused N-G placement.
      • Systemic antibiotic with Cefa 1g Q8H IV for infection control.
      • He finished modified induction chemotherapy with #1a 80% TPF (Taxotere 32mg/M2, Cisplatin 32mg/M2, 5-Fu 800mg/M2 plus Leucovorin 80mg/M2, MTX 24mg/M2) on 2023/05/3-2023/05/06.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Zinga 1 tab PO QD for zinc supplement, B-Red 1 mg IVD QD for hematogenesis, Magnesium Sulfate 10% 20 mL IVD QD for hypomagnesemia.
    • Prescription
      • Actein (acetylcysteine 600mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H (if pain)
      • Zinga (zinc gluconate 78mg) 1# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • loperamide 2mg 2# PRNQ8H (if diarrhea >= 4 times)
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC (if vomit)
  • 2023-04-25 SOAP Oral and Maxillofacial Surgery
    • S: The patient has been missing for 4 months
      • Body: Apart from oral cancer, there are no other systemic diseases,
      • Mind: The patient is not anxious
      • Spirit: No specific beliefs
      • Social: Family’s financial situation is poor (rent is about 30,000, high stress), very thin
    • A: SCC of right tongue (cT3N2bM0) with local inflammation (now progressed to T4bN3bMx)
  • 2022-12-22 ~ 2022-12-26 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination which his ANC showed 3630/mm2.
      • Then we had arranged induction chemotherapy with #3b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/22 - 2022/12/24.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. No obvious of discomfort were noted excepted mild mucositis of right buccal mucosa were noted.
  • 2022-12-15 ~ 2022-12-19 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 2901/mm2.
      • Then we had arrange induction chemotherapy with #3a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/15 - 2022/12/17.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Mouth care and cool soft diet were educated.
    • Prescription
      • Smecta (dioctahedral smectite 3mg) 1# PRNBID (if watery diarrhea > 3 times)
      • Acetal (acetaminophen 500mg) 1# Q8H (if pain)
      • amoxicillin 250mg 2# Q8H
  • 2022-11-28 ~ 2022-12-03 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 3351/mm2.
      • Then we had arrange induction chemotherapy with #2b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/28 - 2022/11/30.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Radi-K 2 tab PO TID for prevent hypokalemia. Zinga 1 tab  PO  QD for zinc supplement. Folina 15mg 1 tab PO QD for hematogenesis. B-Red 1 mg IVD  QD for hematogenesis. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
  • 2022-11-21 ~ 2022-11-25 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 3769/mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed. Then we had arrange induction chemotherapy with #2a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/21 - 2022/11/23.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
    • Prescription
      • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
      • Zinga (zinc gluconate 78mg) 1# QD
      • Folina (folinate 15mg) 1# QD
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2022-11-07 ~ 2022-11-12 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 7918 /mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed.
      • Then we had arrange induction chemotherapy with #1b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/07 - 2022/11/09.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer.
      • Additional, hopeless tooth with local inflammation were noted, We had arranged extraction of 14 15 and curettage of the extraction socket under local anesthesia on 2022/11/11. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 1# HS
      • amoxicillin 250mg 2# Q8H
      • Megest (megestrol 40mg/mL) 10mL BID
  • 2022-10-24 ~ 2022-11-02 POMR Oral and Maxillofacial Surgery
    • Discharge diagnosis
      • Squamous cell carcinoma of right tongue cT4aN2bM0 stage IV in process chemotherapy
      • Malignant neoplasm of border of tongue
      • INFECTION OF TONGUE AND FLOOR OF MOUTH
      • Encounter for antineoplastic chemotherapy
      • HOPELESS CARIES OF MANY TEETH
    • CC
      • HE WAS ADMITTED BECAUSE HE HAD an ulcerative MALIGNANT mass at HIS right tongue for more than 6 weeks    
    • Illness
      • The local finding showed a BIG ulcerative malignant tumor WITH INDURATION AND LOCAL INFECTION at his right tongue border AND VENTRAL SURFACE with muscle invasion, about 5.0 cm in size. BESIDES, several palpate lymph nodes at the right neck are detected. After we had adequately explained the finding and treatment plans to the patient and his WIFE, he recided to accept our treatment plans for him. His treatment plans were induction chemotherapy follow by surgery and CCRT. Under the impression of squamous cell carcinoma of right tongue cT4aN2bM0 stage IV, he was admitted to ward for tumor work up and prepare induction chemotherapy.
    • Inpatient Treatment Process
      • The induction chemotherapy with TPF (Taxotere 40mg/M2, cisplatin 40mg/M2, 5-FU 1000mg/M2) were delivered on 10/28~10/30/2022. He did’t had nausea and vomiting after chemotherapy. Intraoral wound change dressing qd. Mouth care with Parmason solution q3h.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 1# HS
      • loperamide 2mg 1# ASORDER (if diarrhea > 4 times)
      • Promeran (metoclopramide 3.84mg) PRNTIDAC (if N/V)
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2022-10-21 SOAP Oral and Maxillofacial Surgery
    • S
      • He came to our OS OPD for help because is a tongue cancer patient who had been proved in ShuangHe Hospital ENT.
    • O
      • An ulcerative SCC with local inflammation at the right tongue border with muscle invasion, about 4.0 cm in size, is noted. several palpate lymph nodes at the right neck are detected. many hopeless caries are noted. edntulous ridge of mandible was noted. gingivitis and gingival recession of residual teeth are noted. no crown, no bridges and no wisdom teeth are noted.
    • A
      • SCC of right tongue (cT3N2bM0) with local inflammation
    • P
      • Panoramic film showed no bone destruction by tumor. periodontal bone loss is noted.
      • explain the finding and treatment plan to the patient.
      • debridement and cruettage at the right tongue border to remove food debris and necrotic tissue.
      • amoxilline + scanol to control pain and infection.
      • arragne admission for further treatment

[chemotherapy]

  • 2023-05-03 - docetaxel 32mg/m2 50mg NS 100mL 1hr + cisplatin 32mg/m2 NS 150mL 3hr + fluorouracil 800mg/m2 1200mg leucovorin 80mg/m2 120mg NS 1000mL 22hr D2 + methotrexate 24mg/m2 35mg NS 100mL 30min D4
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-12-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-15 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-21 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-07 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-10-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

[assessment]

  • The patient’s weight dropped dramatically from 57kg on 2023-04-25 to 48kg on 2023-05-03, a loss of 9 kilograms in just 8 days. This significant weight loss could be due to a data entry error or rounding inconsistencies, as the patient had a lapse in follow-up between late December 2022 and late April 2023.
  • Even as early as November 2022, there was a need to enhance the patient’s appetite (megestrol was prescribed at discharge on 2022-11-12). As of the most recent chemotherapy session on 2023-05-03, the same regimen was used but the dose was reduced to 80% of the original. It seems unlikely that the recent chemotherapy is the sole culprit for the patient’s severe weight loss.
  • If the patient is still able to consume food orally, it would be advisable to reintroduce megestrol to help stimulate his appetite. This may potentially help to counteract the significant weight loss he has been experiencing.

701470089

230509

[lab data]

  • 2023-03-03 Anti-HBc Reactive
  • 2023-03-03 Anti-HBc-Value 6.75 S/CO
  • 2023-03-03 Anti-HBs 68.82 mIU/mL
  • 2023-03-03 HBsAg Nonreactive
  • 2023-03-03 HBsAg (Value) 0.39 S/CO
  • 2023-03-03 Anti-HCV Nonreactive
  • 2023-03-03 Anti-HCV Value 0.09 S/CO
  • 2023-02-16 MTBC PCR NOT DETECTED CFU/ml
  • 2023-02-16 MTBC PCR Value <11.8 CFU/ml

[exam findings]

  • 2023-04-29 MRI - L-spine
    • Indication: Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, stage IVB. This time, lower back pain for 1 week
    • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
      • Abnormal thick nerve roots and the filum terminale.
      • After IV contrast administration shows well nodular like enhancement along those nerve roots.
      • A small right SI joint lesion, nature?
      • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression at L4/5/S1.
    • IMP: Highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis?
  • 2023-04-27 ECG
    • Decreased disc height at L5/S1 is found.
    • Phlebolith at pelvic cavity is also found.
  • 2023-03-27 CXR
    • Fibrosis of right and left upper lung are suspected.
  • 2023-03-06 Pure Tone Audiometry
    • PTA:
    • Reliability FAIR
    • Average RE 14 dB HL, LE 15 dB HL
    • bil WNL
  • 2023-02-13 CXR
    • widening of Lt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • 2023-02-11 MRI - brain
    • No evidence of intracranial lesion.
  • 2023-02-10 Patho - esophageal biopsy
    • Ulcerative lesion, 19-33 cm below the incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated characterized by solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma without keratin formation and ulcer with necrotic debris.
    • Immunohistochemistry of CK(+), P63(+) and P16(-) for tumor
  • 2023-02-10 SONO - abdomen
    • Suspected liver hemangioma, three
    • Renal stones, both kidney
    • Renal cyst, right kidney
  • 2023-02-10 Miniprobe Endoscopic Ultrasound
    • Highly suspected esophageal cancer, s/p biopsy*6
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • 2023-02-09 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the posterior aspect of right rib cage and increased activity in some middle T-spines, right 9th costovertebral junction, right S-I joint and greater trochanter of right femur in whole body survey.
    • IMPRESSION:
      • Increased activity in some middle T-spines, right 9th costovertebral junction and right S-I joint. Bone metastases should be watched out. Please correlate with other imaging modalities for further evaluation.
      • A faint hot spot in the posterior aspect of right rib cage and mildly increased activity in the greater trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastases?). Please follow up bone scan for further evaluation.
  • 2023-02-08 PET scan
    • Glucose-hypermetabolism in the upper to middle esophagus, compatible with the primary esophageal cancer.
    • Glucose-hypermetabolism in bilateral SCF lymph nodes and bilateral pulmonary hilar and mediastinal lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    • Glucose-hypermetabolism in the left axillary lymph nodes, probably reactive nodes.
    • Glucose-hypermetabolism in bilateral lungs and skeleton including T5, T6 spines, right 9th costovertebral junction, and right iliac bone, highly suspected cancer with distant metastases.
    • Esophageal cancer with regional lymph nodes, bilateral lungs and multiple bones metastases, cTxN3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-08 Nasopharyngoscopy
    • Findings:
      • smooth NPx, OPx, HPx, mild saliva pooling at Hpx, left vocal palsy at paramedian position, congested
    • Diagnosis/conclusion
      • L vocal palsy, related to esophageal ca
  • 2023-02-07 Bronchoscopy
    • Abnormal Tracheal mucosa infiltration due to esophageal cancer invades
  • 2023-02-04 CT - chest
    • Indication: esophageal cancer
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window, 5 mm soft-tissue window slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse ground glass patches at both lungs is found.
        • Diffuse wall thickening at upper third esophagus is found about 8.5cm*1.2 in length and width.
        • Enlaged lymph nodes (n>8) are found around the main mass.
        • No evidence of bilateral pleural effusion.
        • Multiple round solid nodules (each about 0.6cm) scattered in both lungs, favor lung metastases.
      • Visible abdomen:
        • Bilateral renal stones are found.
        • The spleen, pancreas and adrenals are intact.
        • Low density lesion at liver surface measuring 1.7cm is found. Hemangioma is favored.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
    • IMP:
      • Long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered.
      • Diffuse ground glass pacthes at both lungs. Previous repeated inflammation is considered.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M1(M_value) STAGE:IV__(Stage_value)

[consultation]

  • 2023-05-02 Radiation Oncology
    • Q
      • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis? Now, for evaluate palliative radiotherapy to L spine. Thank you.
    • A
      • This 52-year-old man patient is a case of Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, s/p CCRT.
      • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis.
      • Palliative RT is indicated. CT-simulation will be arranged on 2023-05-10. Plan to deliver 30 Gy/ 10 fx to the L-spine and partial S-I joint (at least the Rt side metastatic lesion shown on PET). RT will start around 2023-05-11. Thank you very much.
  • 2023-02-11 Hemato-Oncology
    • A
      • This 52 year old man is a case of esophagus squamous cell carcinoma with lung metastasis, cT3N3M1, stage IV (initial presentation was hoarseness for 3 months and dysphagia with body weight loss). He had been admitted to HsinChu Cathay Hospital on 2023/01/30, where Panendoscope on 2023/01/31 showed esophageal tumor with stricture, biopsy show squamous cell carcinoma, moderate to poorly differentiated. We are consulted for further evaluation.
      • Systemic therapy is indicated for metastasis esophagus SCC. Palliative CCRT followed by systemic chemotherapy may consider in this case. Please arrange our OPD after discharge. Thanks for your consultation.
  • 2023-02-10 Radiation Oncology
    • A
      • This 52-year-old man, a heavy smoker and alcoholism denied any systemic disease. He has suffered from hoarseness since 3 months ago. Dysphagia even liquid diet for 2 weeks, associated with weight loss 4 kg in a month. Endoscopic biopsy was done, and pathology reported squamous cell carcinoma, moderate to poorly differentiated. Chest CT on 2023-02-04 showed long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered. Stage cT3N3M1. Whole body PET and bone scan showed highly suspected spine and lung mets.
      • He can’t swallow the saliva. Palliative CCRT is indicated. CT-simulation will be arranged on 2023/02/16. Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. If the dose distribution is feasible, spine mets can be included in the RT field. RT will start around 2023/02/20 or 21.

[MedRec]

  • 2023-03-02 SOAP Hemato-Oncology
    • A
      • C15.9 Malignant neoplasm of esophagus, unspecified
    • P
      • Admission for systemic chetmoehrapy when admission, 24 hours CCr and audiometry
      • Plan: palliative radiohterapy with systemic chemotherapy followed by paliative C/T with PF
  • 2023-02-24 SOAP Radiation Oncology
    • P: Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF and T-spine mets. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx.

[radiotherapy]

[chemotherapy]

  • 2023-05-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
  • 2023-03-30 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
  • 2023-03-07 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3

2023-05-09

[tube feeding]

Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.

2023-04-28

[tube feeding]

  • All of the oral medications prescribed can be administered via a feeding tube.

2023-03-27

[tube feeding]

  • All of the oral medications in the patient’s active prescription are able to be administered through a feeding tube.

700070514

230508

[diagnosis] - 2023-05-07 admission note

  • K-RAS mutation Adenocarcinoma of the sigmoid colon near complete obstruction invasion to bladder with fistula formation, and carcinomatosis and liver metastases, cT4bN2bM1c, stage IVc status post T-loop colostomy on 2022/10/26
  • Iron deficiency anemia, unspecified

[present illness]

  • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.

[past history] - 2023-05-07 admission note

  • Systemic disease:
    • Major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
  • Surgery:
    • Left femoral fracture s/p THR

[family history]

  • Father has diabetes
  • No cancer history in his family

[lab data]

  • 2022-10-01 HBsAg Nonreactive
  • 2022-10-01 HBsAg (Value) 0.37 S/CO
  • 2022-10-01 Anti-HBc Reactive
  • 2022-10-01 Anti-HBc-Value 5.99 S/CO
  • 2022-10-01 Anti-HCV Nonreactive
  • 2022-10-01 Anti-HCV Value 0.15 S/CO

[exam findings]

  • 2023-05-02, -04-24, -04-22, -03-19 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w lung metastases after correlate with CT.
  • 2023-03-07 CT - abdomen
    • History and indication: Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected and urinary bladder fidtula, cT4bN2bM1c, stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of S-colon cancer and peritoneal invasion but progression of LN/ lung/ liver and left sacral metastases.
      • Left hydronephrosis.
      • S/P left THR.
      • Minimal ascites.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Mild regression of S-colon cancer and peritoneal invasion but progression of LNs/ lung/ liver and left sacral metastases.
      • Left hydronephrosis.
  • 2023-02-03 Tc-99m MDP bone scan
    • Increased activity in the sacrum. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
    • Mildly increased activity in the lower C-spine, some middle and lower T-spines. Degenerative change may show this picture. However, please keep follow-up to rule out other possibilities.
    • Some hot and faint hot spot in bilateral rib cages and increased activity in the right clavicle and right ischium. The nature is to be determined (bone metastases? post-traumatic change? ). Please correlate with other clinical findings for further evaluation.
  • 2023-02-01 Long Bones series
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • S/P total hip arthroplasty, left hip
  • 2022-12-02 CT - abdomen
    • History
      • 20221202 CC: Started to have a fever this morning, vomiting, general weakness, abdominal pain, blood pressure in the right hand 79/52mmhg
      • 20220921 CC: diarrhea for 1/2 yrs. bw loss 14 kg. CEA 33.86; anemia (initial 8.2); favor IDA (iron deficiency anemia)
      • 20220921 sigmoidoscopy: Suspected colon ca, R-S juncton s/p biopsy
      • 20220923 CT: R-S juncton cancer, cT4b(UB)N2bM1c, cSTAGE:IVC
    • Indication: sepsis
    • Findings: Comparison: prior CT dated 2022/09/23.
      • Prior CT identified long segmental sigmoid colon cancer is noted again, stable in size.
        • S/P colostomy at right transverse colon.
        • There is no gas in the urinary bladder.
        • Prior CT identified Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space are noted again, mild increasing in size and number that are c/w progressive disease.
        • In addition, There is mild hydroureteronephrosis and delayed contrast excretion of left kidney and the etiology is due to metastatic node in left common iliac chain with passive compression left side ureter.
      • There are newly-developed multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases with progressive disease.
        • The largest one measuring 5.9 cm in S6/7.
      • Prior CT identified smuddgy appearance of the omentum is noted again, stationary. Follow up is indicated.
      • There are multiple newly-developed soft tissue nodules on both lung that are c/w lung metastases.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & right kidney.
      • There is no evidence of ascites.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Multiple liver and lung metastases c/w progressive disease.
      • Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space show progressive disease.
  • 2022-10-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 35) / 101 = 65.35%
      • M-mode (Teichholz) 65
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Mild MR, trivial TR
    • Preserved RV systolic function
  • 2022-10-31 CXR
    • Pneumoperitoneum (note: Pneumoperitoneum is the presence of air or gas in the abdominal (peritoneal) cavity. It is usually detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT).)
    • A nodule at RLL.
  • 2022-10-25 Barium Enema with water soluble contrast medium
    • Findings
      • Obstruction at sigmoid colon.
      • A defect at between sigmoid colon and urinary bladder. Prominent air the the urinary bladder.
    • Impression
      • Obstruction at sigmoid colon
      • c/w sigmoid colon-vesical fistula (may be dominate at proximal end)
  • 2022-10-05 Whole body PET scan
    • Glucose-hypermetabolic lesions in the lower abdomen, pelvis, and in a left para-arotic lymph node, highly suspected S-colon cancer with carcimatosis.
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected colon cancer with liver metastasis.
    • Increased uptake of FDG at the left hip joint, probably benign in nature.
    • S-colon cancer with carcimatosis and liver metastases, cTxN2bM1c, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-03 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS condon 61 CAA>CTA, p.Q61L)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-30 ECG
    • Sinus rhythm with short PR
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2022-09-23 CT - abdomen
    • Findings:
      • There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction.
        • In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b).
        • In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b).
      • There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). Please correlate with sonography or MRI.
        • The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
  • 2022-09-22 Patho - colon biopsy
    • Colon, R-S junction, biopsy — Adenocarcinoma, moderately differentiated
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-09-21 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, R-S junction, s/p biopsy
      • Mixed hemorrhoid
      • Incomplete colonoscopy due to tumor stricture
    • Suggestion
      • F/U pathology report
      • Further image for cancer staging may be indicated.
    • Complication
      • No immediate complication
  • 2022-08-30 Patho - stomach biopsy
    • Esophagus, EC junction, biopsy — Barrett’s esophagus
    • Microscopically, it shows chronic inflammation with lymphoplasmacytic infiltrate and intestinal metaplasia with goblet cells present.
  • 2022-08-29 SONO - abdomen
    • suspected liver parenchymal disease.
  • 2022-08-29 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Hiatus hernia
      • Suspect Barrett’s esophagus, s/p biopsy, C1M3
      • Superficial gastritis
      • Gastric polyp, high body, GC/PW site
    • Suggestion
      • Pursue biopsy result
  • 2022-08-25 ECG
    • Sinus tachycardia
    • Nonspecific ST abnormality
    • Abnormal ECG

[consultation]

  • 2022-12-07 Colorectal Surgery
    • A: Diver-T-loop colostomy was done, please control underline disease
  • 2022-11-22 Radiation Oncolgoy
    • A
      • The 57 y/o man has adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC. s/p T-colonostomy. Palliative C/T has been started on 2022/11/21.
      • Palliative CCRT is indicated. CT-simulation will be arranged on 11/28. Plan to deliver 45 Gy/ 25 fx to the S-colon tumor and adjacent carcinomatoses. r/o IVC thromboemboli shown on abd. CT (2022/09/23) with PVT? I will consult radiologist Dr. Yu later. Thank you very much.
      • no PVT. just r/o IVC thromboemboli.
  • 2022-10-06 Colorectal Surgery
    • Q
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022/10/04 and PET was arrange on 2022/10/05.
      • we had explained the current condition to patient and family,they agreed to do the T-loop colostomy. We need your expertise for further management, thanks
    • A
      • This is a 57-year old man with the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC,
      • protective T-loop colostomy will be considered
      • we will arrange operation for him
  • 2022-10-05 Radiation Oncology
    • Q
      • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
      • He had suffered from watery diarrhea with body weight loss 17kg in half year. The condition is worse than before within this year. EGD on 2022/08/29 showed Reflux esophagitis LA Classification grade A. Hiatus hernia. Suspect Barrett’s esophagus, s/p biopsy, Superficial gastritis. Gastric polyp, high body, GC/PW site. Biopsy proved Barrett’s esophagus.
      • He came to our GI OPD and colonscopy was performed on 2022/09/21 which showed Highly suspected colon cancer, R-S junction, s/p biopsy. Mixed hemorrhoid. Biopsy proved Adenocarcinoma, moderately differentiated.
      • CT of abdomen was performed on 2022/09/25 revealed There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction. In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b). In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b). There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022-10-04. We need your expertise for radiotherapy evalaution, thanks
    • A
      • He was persuaded to have colostomy first.
      • CCRT will be arranged thereafter.
  • 2022-08-26 Psychosomatic Medicine
    • A
      • MSE: thin and cachexia, impaired attention focus and sustain, low mood, poor energy, psychomotor retardation, suicidal ideation, alcohol drinking all day long.
      • PE: mild upper limb tremor, yellowish skin, icteria scerdela
      • IMP:
        • Major depressive disorder, recurrent, severe
        • Suspected alcohol induced mood disorder
        • Alcohol use disorder, in withdrawal status.
      • Suggestion:
        • Correct electrolytes, treat physical condition
        • Saline hydration with B-complex 1 amp QD, with kentamin supply for B12 defiency.
        • Add dosage of our medications: keep zoloft 50mg 1# QN, add utapine to 25mg 2# HS, Eurodin 1# HS, and add anxiedin to 2# Q12H
        • Arrange psy OPD f/u.

[MedRec]

  • 2023-03-19 ~ 2023-03-24 POMR Hemato-Oncology
    • Inpatient Treatment Process
      • After admission, C6 Avastin plus C2D1 FOLFIRI was administered on 2023/03/21-23.
      • Dizziness and headache was noted during chemotherapy and adequate hydration was done.
      • With the relatively stable condition, he was discharged on 2023/03/24 and will OPD follow up later.
  • 2022-11-29 SOAP Hemato-Oncology
    • A/P: Bevacizumab 5 mg/kg iv q2wks for 36 wks (18 wks each apply) colostomy in late Oct. 2022
  • 2022-09-30 SOAP Hemato-Oncology
    • A/P: Discussed the suggestion of a protective T-loop colostomy with the patient and his wife (which could also help reduce the risk of urinary tract infections). The patient indicated that he is currently able to have bowel movements and would like to try chemotherapy and radiation first.

[surgical operation]

  • 2022-10-26 T loop colostomy        
    • adenocarcinoma of Sigmoid colon with invasion to bladder and fistula formation    
    • short T-colon with adhesion to liver and middle colic mesentery region 

[radiotherapy]

  • 2022-11-29 ~ 2023-01-10 - completed RT to the pelvisthe S-colon tumor, partial bladder, and adjacent carcinomatoses: 45 Gy/ 25 fx.

[chemoimmunotherapy]

  • 2023-04-06 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-03-21 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off due to encephalopathy during last time)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-03-01 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-02-13 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-01-27 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-01-09 - bevacizumab 5mg/kg 245mg NS 100mL 90min + oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-26 - bevacizumab 5mg/kg 255mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-13 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-21 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-05-08

  • From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.

  • After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.

    • 2023-04-21 CEA (nuclear medicine) 1376.700 ng/ml
    • 2023-04-03 CEA (nuclear medicine) 1203.450 ng/ml
    • 2023-03-17 CEA (nuclear medicine) 1261.1 ng/ml
    • 2023-02-24 CEA (nuclear medicine) 1322 ng/ml
    • 2023-02-14 CEA (nuclear medicine) 1371.12 ng/ml
    • 2023-01-27 CEA (nuclear medicine) 667.3 ng/ml
    • 2023-01-09 CEA (nuclear medicine) 627.64 ng/ml
    • 2022-12-29 CEA (nuclear medicine) 907.05 ng/ml
    • 2022-11-29 CEA (nuclear medicine) 382.654 ng/ml
    • 2022-10-07 CEA (nuclear medicine) 52.567 ng/ml
  • The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.

  • The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).

2023-01-10

[drug interaction]

  • The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.

  • Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.

  • Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.

2023-01-09

  • Oxaliplatin is associated with high incidence of peripheral neuropathy (76%, grades 3/4: 7%; acute: 65%, grades 3/4: 5%; delayed (persistent): 43%, grades 3/4: 3%) Ref: UpToDate
  • The acute neurotoxicity that is seen frequently in the 72 to 96 hours after each infusion of oxaliplatin is often linked to cold exposure (drinking cold liquids, inhaling cold air, placing hands in the freezer). Avoidance of cold during this time frame should mitigate this toxicity to some extent, but not all symptoms (eg, perioral numbness, hand cramping) are related to cold. As of now, no evidence of peripheral neuropathy has been recorded.
  • The patient vomited several times throughout the week as documented in the record of 2023-01-06. A prescription for metoclopramide has been issued.

2022-12-26

  • The patient is receiving bevacizumab for the first time during this hospital stay. The patient was recently diagnosed with gastro-esophageal reflux disease (2022-11-17), however, no CVD related records have been kept for the past three months. As bevacizumab is associated with concerns regarding gastrointestinal perforation/fistula, heart failure, and hemorrhage. There may be a need for regular monitoring.

2022-12-05

  • The patient’s body temperature fluctuated between 36.2 and 38.2, with two peaks at around 08:00 and 22:00 on a daily based cycle roughly.
  • In this instance, tapimycin (piperacillin + tazobactam) is used, which has been shown to be effective against the 2022-12-02 blood cultured Escherichia coli (MIC <= 4 mcg/mL according to the lab report).
  • There was a downward trend in renal function, especially in late November 2022, which should be noted. In the event of CrCl < 40mL/min, the dose of tapimycin should be reduced to two thirds.
    • 2022-12-02 Creatinine 0.91 mg/dL
    • 2022-11-28 Creatinine 0.96 mg/dL
    • 2022-11-21 Creatinine 0.59 mg/dL
    • 2022-11-17 Creatinine 0.58 mg/dL
    • 2022-10-31 Creatinine 0.48 mg/dL
    • 2022-10-24 Creatinine 0.43 mg/dL
    • 2022-10-17 Creatinine 0.41 mg/dL

2022-11-21

  • Glomerular hyperfiltration (eGFR 150 2011-11-21, recent peak 229 2022-10-17) was noted. Intraglomerular hypertension, resulting from the transmission of systemic pressures or via glomerular-specific processes, may be deleterious over the long term. The use of NSAIDs (celecoxib in current prescription as a patient-carried item) should be limited to the necessary duration and should not be prolonged.

2022-10-03

  • Hypoalbuminemia (2.8 g/dL 2022-09-30) <= decreased hepatic albumin synthesis <= possible liver mets? (2022-09-23 CT)
  • The use of Alglutol (acamprosate 333mg/tab) 2# TID may be considered as a means of helping the patient quit alcohol following his withdrawal symptoms.

700138669

230508

[diagnosis] - 2023-04-26 admision note

  • Hemoptysis
  • Malignant neoplasm of nasopharynx, unspecified
  • Essential (primary) hypertension
  • Hypertensive heart disease without heart failure

[past history] - 2023-04-26 admision note

  • Nasopharyngenl Carcinoma T4N3M1, stage IVB, proved at 2020/05 at Wan Fang Hospital (No biopsy) s/p radiotherapy to the C- and T- spine bone mets: 21 Gy/ 7 fx. on 2023-01-03 ~ 11, (early termination due to the patient reject) at our hospital
  • hypertension for years with Concor 5mg/tab 0.5tab QD, Bokey 100mg/cap 1cap QD, Cozaar 50mg/tab 0.5tab QD, Norvasc 5mg/tab 0.5tab QD control and the clinic follow-up.
  • hyperlipidemia for years with Lipitor 40mg/tab 1tab QD control and the clinic follow-up.
  • L3 compression fracture without surgery for years.

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-25 Nasopharyngoscopy
    • Findings: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
    • Conclusion: nasopharyngeal carcinoma
  • 2023-02-17, -01-13 Nasopharyngoscopy
    • Findings: rt NP tumor
    • Conclusion: NPC
  • 2022-12-28 Bone Scan
    • Hot areas at the skull base, some C-, T- and lower L-spine, NPC with bone mets shoulde be consideded, suggesting PET scan for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, and knees.
  • 2022-12-19 MRI - nasopharynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Right nasopharynx tumor mass, with skull invasion, extending to right Foramen of ovale, up to 4.5 cm.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple right necrotic LAPs were noted down to supraclavicular fossa.
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • Destruction of right transverse process of T1 also was noted indicating bony metastasis.
    • IMP: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
  • 2022-12-02 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopahrynx, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC stains: CK highlights infiltrative epithelum. EBV (-).
  • 2022-11-23 Nasopharyngoscopy
    • rt NP tumor
  • 2022-11-23 ENT Hearing Test
    • Tymp:
      • R’t type B; L’t type A.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 70 dB HL; LE 56 dB HL.
      • R’t moderaet to profound MHL.
      • L’t mild to severe HL. (BC masking dilemma)
      • Dialogue: R’t 65 dB HL; L’t 45 dB HL.
      • SDT: R’t 60 dB HL; L’t 40 dB HL.
  • 2021-10-26 MRI - L-spine
    • Multiple old compression fractures at T11, L2,3, poor healing at upper L3 body. A left T10/11 perineural cyst.
  • 2018-08-07 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.674 gms/cm2, about 1.2 SD below the peak bone mass (84%) and 1.8 SD above the mean of age-matched people (131%).
    • IMP: osteopenia

[lab data]

  • 2022-12-24 EBV DNA quantative PCR <120 copies/mL
  • 2022-12-01 EB VCA IgA Borderline Ratio
  • 2022-12-01 EB VCA IgA Value 0.9 Ratio
  • 2022-12-01 EBV EA/NA IgA Negative EU/mL
  • 2022-12-01 EBV EA/NA IgA Value 2.97 EU/mL

[consultation]

  • 2023-04-25 Ear Nose Throat
    • Q
      • Chief complaint: coughing of blood with clots this morning
        • difficult swallowing, poor intake, nausea and vomiting, easy choking after eating for months
        • denied fever, respiratory symptoms, or urinary discomfort
      • Past Medical History: NPC, T4N3M1 stage IVB (2020/05)
        • currently R/T at bone metastasis areas
        • hypertension, hyperlipidemia
        • L3 compression
      • History of Operation: denied
      • Regular Medications: Aspirin
    • A
      • A case of NPC end stage, under palliative treatment
      • dysphagia recently, and family ask for NG insertion
      • scope: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
      • status post NG insertion under scope
      • sugget CXR f/u before feeding from NG tube

[MedRec]

  • 2023-04-14 SOAP Hemato-Oncology
    • Plan: referred to hospice care
  • 2023-01-13 SOAP Radiation Oncolgoy
    • She decided to quit RT.
  • 2022-12-30 SOAP Radiation Oncolgoy
    • Plan: CT-simulation will be arranged on 20230102. Plan to deliver 30 Gy/ 10 fx to the C- and T- spine and Rt shoulder bone mets. RT will start around 20230104.
  • 2022-12-23 SOAP Radiation Oncolgoy
    • Plan: arrange bone scan for palliative bone mets RT.
      • RTC: around 1 wk.
  • 2022-12-23 SOAP Hemato-Oncology
    • O
      • 2022/12/19 MRI Nasopharynx: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
    • Assessment:
      • NPC, T4N3M1 stage IVB
    • Plan:
      • apply for major disease
      • refer to the radiation oncologist
      • pain control
  • 2022-11-23 SOAP Hemato-Oncology
    • S
      • She was referred on account of NPC proved at 202005 at Wan Fang Hospital. (No biopsy)
      • No treatment was applied from that time. Hospice care from that time.
      • Headache for 3 weeks, bilateral ear cannal ulceration without discharge from one month ago.
      • Hearing loss progressed
    • Assessment
      • NPC, staging
      • Check MRI
    • Plan
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR
      • refer to the ENT

==========

2023-05-08

  • On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.

  • If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.

2023-04-27

  • Alpraline (alprazolam 0.5mg) 1# HS QD for 28 days and Bokey (aspirin 100mg) 1# QD for 28 days were prescribed at RenJi Hospital on 2023-02-28, with the 2nd refill on 2023-03-27. These medications are not currently shown in the patient’s medicine list. Please consider adding them back if they are still needed for the patient’s ongoing care. (Aspirin should be added to the patient’s medication list only after the hemoptysis has resolved.)

2023-04-26

  • Hemoptysis was noted in the patient. The solitary pulmonary nodule in the left mid-lung zone seen on chest x-ray 2023-04-25 was not seen on chest x-ray 2023-04-26. However, ground-glass opacities remain in the right lower lobe. The patient is currently being treated with Amsulber (ampicillin and sulbactam), Mycostatin (nystatin), and Hemoclot (tranexamic acid) without issues.
  • On 2023-04-26 at 10:31, the patient’s blood pressure was recorded as 177/85. If this elevated level persists, it is recommended that the dosage of Norvasc (amlodipine 5mg) be increased from 0.5 tablet once daily to 1 tablet once daily. If the blood pressure still remains high, then consider increasing Cozaar (losartan 50mg) from 0.5 tablet once daily to 1 tablet once daily as well.

701199326

230508

[exam findings]

  • 2023-05-05, -05-01, -04-24, -04-17, -04-10, -04-08, -03-28, -03-15, -03-01, -02-24 CXR
    • Osteolytic defect in left humeral head is suspected.
    • Please correlate with CT to R/O bony metastasis.
    • S/P port-A implantation.
    • Blunting of bilateral right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2023-04-05 CXR
    • Deformity of left humeral head.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacities in bil. lungs.
    • Presence of ileus.
    • Normal appearance of trachea and bil. main bronchus.
    • Right pleural effusion.
  • 2023-04-05 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Possible Inferior infarct , age undetermined
    • Abnormal ECG
  • 2023-03-10 SONO - joint soft tissue
    • Finding:
      • Bulging of the left ACJ.
      • Heterogeneous hypoechoic appearance of the left supraspinatus tendon.
    • Impression And Suggestions:
      • Left AC distention.
      • Left supraspinatus tendinosis. Please correlate with the clinical presentations.
  • 2023-03-01 Shoulder LT
    • Osteolytic defect and deformity of left humeral head and neck is noted. Please correlate with CT to R/O bony metastasis.
  • 2023-01-04, 2022-12-15, -10-20 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2022-12-17 CT - chest
    • Indication: Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Nodular and mass like lesions (n>5) at both lungs up to 4.09 cm in largest dimension at left lower lobe is found. Lung meta is considered. In comparison with CT dated on 2022-04-14, the lesions enlarged.
        • Miliary lesions scattered at both lungs are found. Lung meta is considered.
        • Collapsed right lower lobe with soft tissue like change attaching to right hemidiaphragm is found.
      • Visible abdomen:
        • s/p RFA at S7, S4 and S6 of liver. No evidence of recurrent/residual tumor at both lobes of liver.
        • The GB is well distended without soft tissue lesion
        • Right hydronephrosis and hydroureter is found. Distal obstruciton is considered
    • Imp:
      • Rectal cancer with bilateral lung meta and bone meta. In progression.
      • Liver meta s/p RFA. NO recurrent/residual tumor at both lobes of liver.
      • Right hydronephrosis and hydroureter, suggest double J catheter placement.
  • 2022-11-02 SONO - abdomen
    • Poor echo window due to bowel gas
    • Chronic liver parenchymal disease
    • Hepatic tumors, two C/W mets s/p MWA
    • Renal cysts, bil
    • Hydronephrosis, right kidney
  • 2022-10-20 CT - abdomen
    • History and indication: rectal ca
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer with liver/ lung metastases s/p operation and RFA.
      • Multiple nodules at bil. lungs.
      • Right hydronephrosis. Bil. renal cysts (up to 1.3cm).
      • A cystic lesion (4.0cm) at LUQ.
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
  • 2022-09-29 Cell block cytology
    • one panc tumor was noted at neck with downstream P duct dilate, s/p FNB.
      • a case of rectal cancer with liver and lung mets
    • 15 cc pink clear fluid — Atypia
    • The smears and cell block show few epithelial clusters with mild enlarged nuclei. Please correlate with S2022-16564 for conclusive diagnosis.
  • 2022-09-29 Patho - pancreas biopsy
    • Labeled as “pancreas”, needle biopsy — benign pancreas tissue with fibrosis.
    • IHC stains: CK highlights regular acinar structures. CD56 (-).
  • 2022-08-16 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, body
    • Duodenal ulcer scar, bulb, AW site
  • 2022-07-20 CT - abdomen
    • History: Rectal cancer with liver and lung metastasis, stage IV
      • rectal ca with liver mets at inital s/p op then two liver mets s/p RFA at VGH, then lung mets, refer for r/o liver mets
      • 20220120 CT: Several poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
      • 20220211 S/P MWA for liver tumor
    • Findings:
      • There are four poor enhancing lesions measuring 3.5 cm in S8, 6.7 cm in S4/8, 8.7 cm (the largest dimension) in S7 liver and 2.4 cm in S5 liver that are c/w metastases S/P MVA.
      • Some soft tissue nodules in RUL, RLL, LUL, and LLL of the lung are noted that are c/w lung metastases.
        • In addition, There are several enlarged nodes in paratracheal space that are c/w metastatic nodes.
      • Encapsulated fluid collection in right CP angle pleura space with passive atelectasis and few linear hyperdense shadow are noted. please correlate with clinical history.
      • S/P LAR with autosuture retention over the rectum.
  • 2022-07-20 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2022-06-14 SONO - abdomen
    • Chronic liver parenchymal disease
    • Hepatic tumors, two C/W mets s/p MWA
    • Renal cysts, bil
  • 2022-06-14 Esophagogastroduodenoscopy, EGD
    • Suboptimal study due to much food residual retention at stomach
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis,body, s/p CLO test
    • Duodenal ulcer scar, bulb, AW site
    • Duodenal shallow ulcer, 2nd portion
  • 2022-04-14 CT - lung/mediastinum/pleura
    • Bilateral pulmonary metastasis with progression.
    • Consolidation over right lower lobe with right pleural effusion.
    • Heterogeneous low density lesions are found at residual right lobe liver is found. Liver hematoma is favored.
  • 2022-02-16 Abdominal Ultrasonography
    • chronic liver parenchymal disease
    • hepatic tumors, three c/w mets s/p MWA
    • ascites, mild
    • subcapsule hematoma
    • GB sludge
  • 2022-02-11 CT - liver, spleen, biliary duct, pancreas
    • Hematoma in S4-8 of the liver subcapsule is noted.
    • Hematoma or bloody ascites in subphrenic space, perisplenic space, and bilateral paracolic gutter space.
  • 2022-01-20 CT - liver, spleen, biliary duct, pancreas
    • Rectal cancer with liver/lung metastases s/p operation and RFA. Segeral poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
    • Right pleural effusion with adjacent lung collapse. Some nodules at bil. basal lungs c/w metastases.
  • 2022-01-13 CT- lung/mediastinum/pleura
    • Colon cancer with liver and lung meta s/p op. and RFA at both lungs. Recurrent/residual tumor at both lungs and liver, suggest further treatment.
  • 2021-09-28 Patho - pleura/pericardial biopsy
    • Lung and pleura, right, decortication
      • empyema
      • metastatic adenocarcinoma, moderately differentiated, consistent with colonic origin
    • IHC: CK7(-), CK20(-), CDX2(focal +), and TTF-1(-). The results are consistent with metastatic colonic adenocarcinoma.
  • 2021-09-21 CT - lung/mediastinum/pleura
    • S/P right lung operation. Right pneumothorax with right lung collapse. Right pleural effusion. Some patchy densities at left lung.
  • 2021-07-27 CT - lung/mediastinum/pleura
    • bilateral pulmonary metastatic tumors, in progression compared with CT on 20210311.
  • 2021-03-29 Patho - lung wedge biopsy
    • Pathologic Diagnosis
      • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lung, left, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobe (S2021-4686)
      • Histologic Type (select all that apply): Adenocarcinoma; The morphology is consistent with metastatic colonic tumor.
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): present
      • Direct Invasion of Adjacent Structures: No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 9: 0/1
      • Extranodal Extension: Not identified
      • Additional Pathologic Findings: No tumor is seen in specimen A.
  • 2021-03-11 CT - chest
    • Multiple spiculated nodules, in enlargement. Compatible with lung mets.
  • 2021-03-04 CT - abdomen
    • Mild decreased size of liver metastases. Small nodules at bil. lower lungs.
    • Left hydronephrosis and hydroureter. Bil. tiny renal stones.
  • 2020-12-30 CT - abdomen
    • Two metastases in S7/8 and S7 show stable disease.
    • Two lung metastases show stable disease.
  • 2020-09-23 CT - abdomen
    • Two metastases in S7/8 and S7 show stable disease.
    • A metastasis 5 mm in LUL of the lung is suspected.
    • Left L/3 ureter stone causing hydroureteronephrosis and delayed contrast excretion of left kidney.
  • 2020-07-19 CT - chest
    • right pneumothorax
    • suspicious a nodular lesion, about 20mm, in the lower lobe of the right lung.
  • 2020-07-02 Patho - lung wedge biopsy
    • Lung, right, middle lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
    • Lung, right, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
  • 2020-07-01 Patho - lung wedge biopsy
    • Lung, right, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes (S2020-8766 and S2020-8767)
    • IHC: MSH2(+), MSH6(+), MLH1(+), and PMS2(+).

[consultation]

  • 2023-04-18 Ear Nose Throat
    • Q
      • for tinnitus & obstruction sensation for one day
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. He complained of tinnitus & obstruction sensation for one day. We need expertise to evaluate his condition thanks!
    • A
      • S
        • Hx of COM and OME?
        • Complained of aural fullness, s/s relieved intermittently via Vasalva maneuver
      • O
        • Ear: bil intact, no sign of OME
        • NPx: smooth via scope
      • Imp: Eustachian tube dynsfuction
      • Plan:
        • May try Sindecon nasal spray 2 puff QD per NA
        • Explained th further tx of ventilation tube insertion and tuboloplasty to patient
  • 2023-04-06 Family Medicine
    • Q
      • for share care or hospice care
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. Owing to disease progression noted and we explained his poor condition to patient and DNR was consented. We need expertise to evaluate his condition thanks!
    • A
      • 59 y/o gentleman Advanced Colon cancer
      • DNR(+)
      • Our share care would follow up.
      • Would put p’t on hospice ward list if family agree.
  • 2023-03-23 Infectious Disease
    • Q
      • The 59 y/o male was Dx: (1) COVID-19 (2) Pneumonia (3) Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis . Allergy: Penicillin. We need your expertise for further treatment. Thank you very much
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRP
  • 2023-02-27 Rehabilitation
    • Q
      • for left hand pain & limited of activity (unable to raise hands)
      • for nerve block or steroid treatment
      • This 60-year-old man, a patient of colon cancer with liver & lung mets S/P C/T. He was admitted due to pneumonia for anti treatment. He complained of left hand pain & limited of activity (unable to raise hands) for days. We need expertise to evaluate his condition thanks!
    • A
      • The patient complained left shoulder pain and ROM limitation for at least 1 year, rather than left hand pain or weakness.
        • Due to left shoulder pain and ROM limitation, we were consulted for further evaluation and treatment.
        • Present illness: The patient fell in 2021/11 with hitting to left shoulder. The pain and ROM limiation progressed. He had a diagnosis of left rotator cuff tear 0.5cm over left shoulder in other rehab clinic, and recieved prolo-injection with glucose, amniotic membrane (2022/09) or steriod injection, but all in vain during 2022 ~ 2023.
      • Left shoulder ROM(a/p)
        • Flex: 30’/90’
        • ABD: 30’/80’
        • Ext.: 70’/75’
        • Int: 15’/15’
      • Left shoulder sonogram at 2023/2/27 1700:
        • No tear was noted. (but we could not see all tendon part due to severe ROM limiation)
        • SS tendinitis.
      • Assessment
        • Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
        • r/o left frozen shoulder
      • Plan
        • Please send patient to 5F Sono Room at 20230303 08:30 for treatment
        • Please arrange left shoulder X ray
        • Please arrange rehab OPD follow up after discharge
  • 2022-09-29 Ophthalmology
    • Q
      • this consultation is for right eye foreign body sensation management.
      • We have arranged EUS FNB for gastric submucosal lesion on 2022/09/28. After he came back from examination room, he complained right eye foreign body sensation and painful sensation. The symptom persisted after ice packing. He had no blurred vision, visual field defect. There was also no swelling nor subconjuntival hemorrhage noted. Due to above reason, we sincerely need your expertise for right eye foreign body sensation management.
    • A
      • S OD FBS since yesterday
      • O
        • FBS, tearing
        • EUS FNB under aesthesia yesterday
        • rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B
        • denied oph hx
        • nka
        • BCVA od 0.8x-1.75/-1.0x25 os 0.9x-1.50/-0.50x80
        • IOP 14/13mmHg
        • Pupil 3/3 +/+
        • conj np ou
        • K od peripheral ED 3*2.8mm, no infiltration os clear
        • AC D/cl ou
        • Lens ns+ ou
      • A Corneal ED od
      • P
        • Cravit 1gtt qid + duratear 1qs bid od
        • inform the risk of infection, if worsen vision, come back asap
        • the patient will follow at LMD first
  • 2022-09-24 General and Gastroenterological Surgery
    • Q
      • this consultation is for gastric submucosal lesion management.
      • This 59 y/o man is a case of rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B. He had sudden onset of epigastric pain on 2022/09/22 and went to Tamsui Mackey’s ER for help. PES and abdominal CT showed a huge submucosa tumor around 6.2cm at posterior wall of the body. He was suggested admission but patient refused and visited our ER for his previous medical record at our hospital.
      • Due to above reason, we sincerely need your expertise for gastric submucosal lesion management. Thanks!
    • A
      • A case of rectal ca with liver and lung meta s/p tx
      • sudden on set of upper abd pain and CT scan revealed an submucosal gastric mass that was not noted at last two months CT scan.
      • gastric submucosal tumor with bleeding may considered. I wound like to suggested EUS and aspiration cystology to proved any tumor present, Thanks and let me know if there is any tumor present.
  • 2022-02-11 Diagnostic Radiology
    • Q
      • FOR ANGIO.
      • this is a 58 y/o, a case of rectal ca with liver and lung meta. s/p RFA on 2022/02/11.
      • CTA showed HYPODENSE LESION over RUQ, r/o hematoma after RFA.
      • we need your expertise for angio.
    • A
      • According to the clinical condition and imaging findings, angiography is indicated.
  • 2021-09-21 Thoracic Surgery
    • Q
      • dyspnea.
      • chest ct in 2021/07: bilateral pulmonary metastatic tumors, in progression compared with CT on 2021/03/11.
    • A
      • The patient had metastastic lung cancer s/p RF, Rt. treatment recently.
      • Dyspnea, hemoptysis and hemopneumothorax was found today
      • Suggestion:
        • Catheter drainage
        • ICU monitoring
  • 2021-09-17 Diagnostic Radiology
    • Q
      • Purpose: for lung nodules RFA, right
      • This 58-year-old a case of Rectum cancer metastasis to liver and lung.
      • Rectum cancer with liver and lung metastases, cT3N1M1, stage IVB s/p neoadjuvant short radiotherapy s/p subsegmentectomy, ypT3N2aM1,s/p chemotherapy and RFA
      • There were no discomfort was told, included cough, sputum, chest pain, chest tightness and hemoptesis.
      • We need your help to arrange right lung nodules RFA on 2021-09-16 12:30. Thank you very much.
    • A
      • CT guided RFA for lung tumor is scheduled at 12:30 2021/09/16. Thank you for your consultation.
  • 2020-07-20 Thoracic Surgery
    • Q
      • PH: rectal cancer ; lung cancer s/p op this July
      • allergy: penicillin
    • A
      • I will take over this case. Thanks for your consultaiton!!

[surgical operation]

  • 2022-02-11 MWA, Microwave ablation

    • Procedure
      • Liver metastatic tumors, three (5.5 cm, 2.5 cm and 1.9 cm) s/p MWA x (total 11 sessions)
    • Course
      • By sono-guided, MWA probe was inserted to the 1st tumor (total 9 sessions; 100 W, 5 mins). MWA probe were inserted to the other two tumors (total 2 sessions; 70 W, 3 mins). The patient tolerated the procedure. IV anesthesia was performed during the procedure.
    • Findings
      • A 5.5 cm tumor was noted at S7 near diaphragm. A 2.5 cm mass at rt post seg near liver surface. A 1.9 cm mass at rt ant seg near liver surface.
  • 2021-09-27 VATS, decortication

    • Loculated serosanguenous pleural effusion with fibrotic debris over visceral and parietal pleura
    • Necrotic RLL parenchyma were bleeding during debridement s/p 4D field hemostatic powder treatment
  • 2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis

    • multiple solid nodules over LUL and LLL r/o rectal cancer metastasis
    • LUL nodules x7 and LLL nodules x3 were resected with one of the maximum about 1cm in diameter
    • no noted pleural effusion. Intrapleural cavity adhesion s/p pneumolysis
  • 2021-09-16 RFA, Radiofrequency Ablation

  • 2021-08-19 RFA, Radiofrequency Ablation

  • 2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication        

    • Multiple lung nodules were noted over right lung field.
  • 2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)

[radiotherapy]

  • 2018-002-01 ~ 2018-02-06 - neoadjuvant short radiotherapy of 25Gy/5fx for adenocarcinoma of lower rectum with liver mets, at Taipei Veterans General Hospital

[chemoimmunotherapy]

  • 2023-01-31 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + irinotecan 175mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-01-04
  • 2022-12-15
  • 2022-11-21
  • 2022-10-31
  • 2022-09-05
  • 2022-08-16
  • 2022-07-19
  • 2022-06-30
  • 2022-06-06
  • 2022-05-03
  • 2022-04-19 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-07-14 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-06-21
  • 2021-05-27
  • 2021-05-04 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-02-17 - bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-02-02
  • 2021-01-13
  • 2021-12-30
  • 2020-12-09
  • 2020-11-25
  • 2020-11-10
  • 2020-10-27
  • 2020-10-13
  • 2020-09-29
  • 2020-09-15
  • 2020-09-01 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-08-18 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-08-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 140mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[note]

FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559

  • Cycle length: 14 days.

  • Regimen

    • Irinotecan
      • 165 mg/m2 IV
      • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Levoleucovorin
      • 200 mg/m2 IV
      • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2400 to 3200 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.
  • Pretreatment considerations:

    • Emesis risk
      • HIGH (>90% frequency of emesis).
    • Prophylaxis for infusion reactions
      • There is no standard premedication regimen.
    • Vesicant/irritant properties
      • Oxaliplatin and fluorouracil are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
    • Infection prophylaxis
      • Routine primary prophylaxis with G-CSF is not warranted (estimated risk of febrile neutropenia 5%). However, given the high rate of grade 3 or 4 neutropenia (approximately 50%), primary prophylaxis may be considered for high-risk patients.
    • Dose adjustment for baseline liver or renal dysfunction
      • A lower starting dose of oxaliplatin and irinotecan may be needed for patients with severe renal insufficiency.[4,5] A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
    • Maneuvers to prevent neurotoxicity
      • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
    • Cardiac issues
      • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
  • Monitoring parameters:

    • CBC with differential and platelet count prior to each treatment.
    • Assess electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
    • Irinotecan is associated with early and late diarrhea, both of which may be severe. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine for later cycles.
    • Assess changes in neurologic function prior to each treatment.
  • Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)

    • Myelotoxicity
      • Do not retreat unless granulocyte count >= 1500/microL and platelet count is >= 75,000/microL.
      • Neutropenia:
        • If day 1 treatment delayed for granulocytes < 1500/microL or febrile neutropenia or grade 4 neutropenia > 7 days, reduce irinotecan dose to 150 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. If nonrecovery after two weeks, delay or third occurrence of granulocytes < 1500/microL on day 1, or febrile neutropenia or grade 4 neutropenia at any time during cycle, discontinue treatment.
      • Thrombocytopenia:
        • If day 1 treatment delayed for platelet count is < 75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 150 mg/m2. If nonrecovery after two weeks delay or third occurrence of platelets < 75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 150 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
    • Diarrhea
      • Do not retreat with FOLFOXIRI until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 150 mg/m2 and the continuous FU dose to 75% of original dose. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
    • Mucositis or palmar-plantar erythrodysesthesia
      • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
    • Neurotoxicity
      • For transient grade 3 paresthesias/dysesthesias or grade 2 symptoms lasting more than seven days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
      • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
    • Pulmonary toxicity
      • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
    • Cardiotoxicity
      • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
    • Other toxicity
      • Any other toxicity >= grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
      • For other nonhematologic toxicities, if grade 2, hold treatment until ≤grade 1; if grade 3 or 4, hold treatment until ≤grade 2.[5]
    • If there is a change in body weight of at least 10%, doses should be recalculated.

2023-05-08

  • Blood culture results from 2023-05-04 and 2023-04-27 indicate that Acinetobacter nosocomialis is susceptible to cefepime with a MIC of 2 ug/mL and levofloxacin with a MIC of less than 0.12 ug/mL. Cefepime has been administered since 2023-04-25, while levofloxacin was administered between 2023-04-06 and 2023-04-20. Since the 2023-05-08 CXR shows no significant improvement in the pneumonia, it might be appropriate to consider including meropenem or imipenem-cilastatin as potential next candidate antibiotics for treatment.

[tube feeding]

  • Since Harnalidge (tamsulosin 0.4mg PO QDAC) is not suitable for tube feeding, it is recommended to switch to Urief (silodosin 8mg PO QD) as an alternative for the patient’s needs.

2023-04-25

  • On 2023-04-25, the patient’s CRP was 4.03mg/dL, WBC count was 23.36K/uL, and neutrophils were at 89.1%. Tachycardia and tachypnea were also observed, along with a body temperature exceeding 38 degrees Celsius in the morning. Signs of lung infection remain evident. Cefim (cefepime) at 2000mg Q8H has been administered, and blood culture results are pending. Cravit (levofloxacin) was used for 2 weeks prior to cefepime.
  • Ipratran (ipratropium bromide), Sindecon (oxymetazoline), Actein (acetylcysteine) and Medason (methylprednisolone) are used to relieve respiratory symptoms.
  • The patient’s underlying conditions are being managed with appropriate medications: hypothyroidism is treated with Eltroxin (levothyroxine), HTN with Amtrel (amlodipine and benazepril), constipation with Through (sennoside), BPH with Harnalidge (tamsulosin), oral thrush with Mycostatin (nystatin) and pain with morphine and fentanyl.
  • No medication reconciliation issues have been identified after reviewing the PharmaCloud database. As the lab results indicate generally normal liver and kidney function, there is no need to adjust the drug dosages for liver or kidney-related reasons.
  • The patient has experienced a weight loss of more than 5 kg in the past two weeks (48.7 kg on 2023-04-05 and 54.5 kg on 2023-04-19). Adequate nutritional support may be needed to address this problem.

2022-04-20

  • This patient has MMR-proficient lower rectal cancer with liver and lung metastases (2020-07-01 pathology). The lung mets were confirmed to be in progress (2022-04-14 CT) followed by the MWA (2022-02-11) for the liver mets.
  • During this hospital stay, the patient resumed using FOLFOXIRI plus self-paid bevacizumab and pembrolizumab as a palliative treatment, the same regimen was used during 2021-05-04 to 2021-07-14. Before that, FOLFOXIRI plus bevacizumab were also used from August 2020 to February 2021.
  • Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal.
  • The nursing note does not indicate any intolerances so far since this hospitalization. No issue with current medication.

700358146

230505

{not completed}

[MedRec]

  • 2023-05-05 POMR progress note
    • Leukocytosis, suspect CML
      • Assessment: improved (WBC 225330 -> 72330 -> 71950 -> 64290 /uL)
      • Plan:
        • Bone marrow biopsy performed on 2023/05/02
        • Plasma exchange + Vitacal 60mL IVD for calcium supplement on 2023/05/02
        • Hydrea 500 mg/cap 2# BID start from 2023/05/02
    • Type 2 diabetes mellitus
      • Assessment: stable
      • Plan:
        • Januvia 100mg/tab 1# QD
        • Glucose one touch QDAC
        • Diet modification
    • Hypertension and hyperlipidemia
      • Assessment: stable
      • Plan:
        • Norvasc 5mg/tab 1# QD
        • Crestor 10mg/tab 0.5# QD
    • Hypokalemia + hypomagnesemia
      • Assessment: improving
      • Plan:
        • 0.298% KCl in 0.9% NaCl Injection 500 mL BID
        • Magnesium Sulfate 10% 20mL BID
  • 2023-04-27 SOAP Hemato-Oncology
    • S
      • Referred for leukocytosis noted on 2023-04-27.
      • Occupation touched paint solvent in the past
    • O
      • 2023/04/26
        • Band = 12.0 %;
        • Neutrophil = 51.0 %;
        • Lymphocyte = 2.0 %;
        • Monocyte = 6.0 %;
        • Eosinophil = 0.0 %;
        • Basophil = 1.0 %;
        • Metamyelocyte = 10.0 %;
        • Myelocyte = 3.0 %;
        • Promyelocyte = 15.0 %;
        • WBC = 104.08 x10^3/uL;
        • RBC = 3.61 x10^6/uL;
        • HGB = 11.6 g/dL;
        • HCT = 34.9 %;
        • MCV = 96.7 fL;
        • MCH = 32.1 pg;
        • MCHC = 33.2 g/dL;
        • PLT = 380 x10^3/uL;
        • RDW-CV = 16.1 %;
        • MPV = 11.1 fL;
    • A/P
      • Admission for BM study and leukopheresis
      • Already request patient to ER if any condition

[exam findings]

  • 2023-05-02 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Myeloproliferative neoplasm (Differential diagnosis: Chronic myeloid leukemia and, … etc.)
      • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study (BCR/ABL), flow cytometery and clinical findings is recommended.
    • Microscopically, it shows nhyper cellularity (> 95%), 10:1 of M:E ratio. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in increased in numbers (6~8 per HPF) and demonstate hypholobulated morphologic pattern. Blast-like cells (CD117+, < 5%) are present.
    • Immunohisotchemical stain reveals CD34(-), CD138(focal+, 1~2%), MPO(+), CD71(focal +), CD61(+).

[assessment - not posted]

  • Hyperleukocytosis has been mitigated by the administration of Hydrea (hydroxyurea 500mg) 2# BID since 2023-05-02.
    • 2023-05-05 WBC 64.29 x10^3/uL
    • 2023-05-04 WBC 71.95 x10^3/uL
    • 2023-05-03 WBC 72.33 x10^3/uL
    • 2023-05-02 WBC 225.33 x10^3/uL
    • 2023-05-02 WBC 107.47 x10^3/uL
    • 2023-04-30 WBC 90.67 x10^3/uL
    • 2023-04-29 WBC 93.95 x10^3/uL
    • 2023-04-26 WBC 104.08 x10^3/uL
  • While allopurinol or febuxostat might be considered for prophylaxis of potential tumor lysis syndrome, laboratory data shows a decrease in serum uric acid levels.
    • 2023-05-03 Uric Acid 6.9 mg/dL
    • 2023-04-30 Uric Acid 8.1 mg/dL
    • 2023-04-29 Uric Acid 8.3 mg/dL

700514733

230505

[exam findings]

  • 2023-04-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette
  • 2023-04-13 All-RAS + BRAF
    • ALL-RAS: Detected(KRAS codon 12 GGT>AGT, p.G12S)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-31 CT - abdomen
    • CC: BW loss (+), anemia
      • 20230320 colonoscopy: An ulcerative tumor with lumen obstruction was noted at level probably at ascending colon
      • PATHO: Adenocarcinoma, moderately differentiated
    • Findings:
      • There is segmental circumferential asymmetrical wall thickening at the ascending colon with irregular contour and adjacent omentum fatty stranding, measuring 8 cm in length that is c/w adenocarcinoma (T4b).
        • In addition, there are seven enlarged nodes in the adjacent mesocolon (N2b).
      • There is mild ascites in the cul-de-sac.
      • There is a small soft tissue nodule in RLL of the lung, measuring 3 mm in size at lung window setting.
        • Follow up chest CT 3 months later is indicated.
      • There are several stones in the distal CBD.
        • In addition, there are multiple gallstones.
      • The spleen shows prominence in size (long axis:11.4 cm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-03-27 Bronchodilator Test
    • Normal ventilatory function
    • Not significant bronchodilator reversibility
  • 2023-03-21 Patho - colon biopsy
    • Colon, ascending, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2023-03-20 Colonoscopy
    • Colon cancer, ascending colon, s/p biopsy
    • Colon polyp, transvers colon, s/p biopsy
    • Internal hemorrhoid
  • 2023-03-20 Esophagogastroduodenoscopy, EGD
    • Superfical gastritis, antrum
    • Duodenal ulcer scar, bulb, LC
  • 2023-03-03, -02-27 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and mild pleura effusions are seen. Acute pulmonary edema is highly suspected.
  • 2023-02-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (171 - 64) / 171 = 62.57%
      • M-mode (Teichholz) = 62
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA and LV, elevated LA filling pressure
      • Mild to moderate TR, moderate MR, PR
      • Pulmonary hypertension
  • 2023-02-23 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
  • 2023-02-23 SONO - nephrology
    • No significant abnormality from echography for both kidneys.
    • Bilateral plerual effusion.

[MedRec]

  • 2023-04-12 ~ 2023-04-15 POMR Hemato-Oncology
    • Discharge diagnosis
      • adenocarcinoma, moderately differentiated of colon cancer T4N2bM0 stage IIIC S/P C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
      • chronic viral hepatitis B without delta-agent HBsAg positive
    • CC
      • for C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • loperamide 2mg 1# PRNQ6H 7D (if watery diarrhea > 3 times)
      • Roumin (prochlorperazine maleate 5mg) 1# TID 7D (note: used to treat severe nausea and vomiting)
  • 2023-04-07 SOAP Hemato-Oncology
    • O
      • 2023/04/07 CA-199 (NM) = 192.235 U/ml;
      • 2023/04/07 CEA (NM) = 347.620 ng/ml;
    • A/P
      • arrange admission on April 10 + port-A chemotherapy
  • 2023-04-06 SOAP Colorectal Surgery
    • A/P
      • Lung nodule, cause ?? metastasis ??
      • Advanced A-colon cancer with retroperitoneal invasion;
      • Suggest systemic chemotherapy +/- target therapy for tumor shrinkage and may increase resectability
  • 2023-03-15 SOAP Hemato-Oncology
    • O
      • 2023/03/08 FKLC = 39.3 mg/L;
      • 2023/03/08 FLLC = 51.0 mg/L;
      • 2023/03/08 FK/FL ratio = 0.77 ratio;
      • 2023/03/04 M-peak = Positive;
      • 2023/03/04 Stool OB (LIA) = Positive;
      • 2023/03/04 Occultblood (LIA) quantitative value = >999 ng/mL;
      • 2023/03/03 B2-Microglobulin = 2906 ng/mL;
      • 2023/03/02 Ferritin = 23.1 ng/mL;
      • 2023/02/27 WBC = 9.48 x10^3/uL;
      • 2023/02/27 HGB = 8.7 g/dL;
      • 2023/02/27 PLT = 412 x10^3/uL;
      • 2023/02/24 OB = Negative;
      • 2023/02/24 Fe (Iron-bound) = 363 ug/dL;
      • 2023/02/24 TIBC = 442 ug/dL;
      • 2023/02/24 UIBC = 79 ug/dL;
    • A/P
      • suggest to check bone marrow
      • patient is scheduled to check colonfibroscopy at 2023/03/20
      • wait the colonfibroscopy result.
  • 2023-02-23 ~ 2023-02-27 POMR Cardiology
    • Discharge diagnosis
      • Heart failure, EF 62%, moderate MR, NT pro BNP 1812
      • Anemia, Fe 363, stool OB negative
      • Essential (primary) hypertension
      • Hypoalbuminemia, proteinuria(+/-)
    • CC
      • bilateral lower limbs edema and exertional shortness of breath progressively for the past 2 weeks
    • Discharge prescription
      • spironolactone 25mg 0.5# QD 5D
      • Zanidip (lercanidipine 10mg) 0.5# QD 5D
      • Ulstop (famotidine 20mg) 1# BID 5D
      • Torsix (torsemide 5mg) 1# QD 5D
      • Torsix (torsemide 5mg) 0.5# PRNQD 5D (prepared for BW increase > 0.5kg or edema)
      • Blopress (candesartan 8mg) 1# QD 5D
  • 2023-02-23 SOAP Nephrology
    • S
      • Bilateral lower leg edema for one week
      • DOE (+) for one week
      • Orthopnea (-) PND (-)
      • Foamy urine (-)
      • PH: DM (-) HTN (-) Drug allergy: denied
      • Herb use : denied
      • To ER for CHF with severe anemia.
    • O
      • BP:170/54; HR:105;
      • BW not measured
      • Leg edema (+++)
      • CVA knocking pain (-)
      • BS: clear
      • NT-proBNP elevated
      • Bilateral pleural effusion
      • Hb 4.4
      • MCV 56.9
      • Urine examination: not collected
    • A/P:
      • Refer to ER for suspected CHF with severe anemia.

[chemoimmunotherapy]

  • 2023-05-04 - cetuximab 500mg/m2 700mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3360mg NS 500mL 46hr (cetuximab + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL
  • 2023-04-13 - cetuximab 400mg/m2 500mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (cetuximab + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL

[assessment]

  • Microcytic anemia, possibly caused by iron deficiency, has been present in the patient’s laboratory data for months, with low RBC, HGB, MCV, MCH, MCHC, and high RDW, even before the start of Cetuximab/FOLFIRI chemoimmunotherapy. Iron supplementation is recommended. After the planned blood transfusion, the addition of an oral form such as Foliromin tablets (ferrous sodium citrate 50mg) or Ferrum Hausmann drops (ferric hydroxide polymaltose complex) or an injectable form such as Ferrum (ferric hydroxide sucrose) may be considered.
    • 2023-05-04 HGB 7.7 g/dL
    • 2023-04-21 HGB 8.5 g/dL
    • 2023-04-12 HGB 7.0 g/dL
    • 2023-03-31 HGB 7.1 g/dL
    • 2023-02-27 HGB 8.7 g/dL
    • 2023-02-24 HGB 7.7 g/dL
    • 2023-02-23 HGB 4.4 g/dL
    • 2023-05-04 MCV 76.8 fL
    • 2023-04-21 MCV 76.8 fL
    • 2023-04-12 MCV 74.9 fL
    • 2023-03-31 MCV 74.3 fL
    • 2023-02-27 MCV 71.1 fL
    • 2023-02-24 MCV 66.6 fL
    • 2023-02-23 MCV 56.9 fL
    • 2023-05-04 MCH 22.3 pg
    • 2023-04-21 MCH 22.9 pg
    • 2023-04-12 MCH 21.7 pg
    • 2023-03-31 MCH 21.0 pg
    • 2023-02-27 MCH 20.4 pg
    • 2023-02-24 MCH 19.6 pg
    • 2023-02-23 MCH 14.9 pg
    • 2023-05-04 MCHC 29.1 g/dL
    • 2023-04-21 MCHC 29.8 g/dL
    • 2023-04-12 MCHC 28.9 g/dL
    • 2023-03-31 MCHC 28.3 g/dL
    • 2023-02-27 MCHC 28.7 g/dL
    • 2023-02-24 MCHC 29.5 g/dL
    • 2023-02-23 MCHC 26.2 g/dL
    • 2023-05-04 RDW-CV 22.7 %
    • 2023-04-21 RDW-CV 23.5 %
    • 2023-04-12 RDW-CV 27.0 %
    • 2023-02-24 RDW-CV 30.5 %
    • 2023-02-23 RDW-CV 21.2 %

700732120

230505

{not completed}

[MedRec]

  • 2021-03-30 ~ 2021-05-06 POMR General and Digestive Surgery
    • Discharge diagnosis
      • Adenocarcinoma of renmant anterior gastric with liver S2-3 invasion, pT4bN2(cM0); pStage: IIIB, status post total gastrectomy with splenectomy + en block S2-3 resection and lymph node dissection on 2021/04/22. ECOG:2
      • Malignant neoplasm of stomach, unspecified
      • Distal common bile duct stone status post common bile duct explore with stone resection with scope and common bile duct primary repair on 2021/04/22.
      • Bacteremia due to Acinetobacter ursingii related
      • Hypoalbuminemia
    • CC
      • RUQ abdominal pain with radiation to back for over 1 week

[surgical operation]

  • 2021-04-22
    • Surgery
      • total gastrectomy with splenectomy
      • en block S2-3 resection
      • retreoperitoneal LN dissection
      • CBDE with stone retraction with scope and CBE primary repair
    • Finding
      • 7 x 6.5 cm ulcerative mass at renmant anterior stomach with S2-3 invasion
      • multiple LN enlarge at 7,8,9
      • multiple pigment stones at distal CBD with CBD 1.8cm diameter

[medication]

2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID

2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID

2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID

B-Red (hydroxocobalamin 1mg)

700930564

230505

[diagnosis] - 2023-03-22 SOAP

  • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
  • gastric adenocarcinoma in situ

[past history]

  • Denied TB, Asthma, DM, HTN or Malignancy diseases.
  • No known allergens
  • Denied other admission or operation history.    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-05-02 Ascites Tapping
    • 3000ml yellowish color ascites were drained.
  • 2023-04-28 ECG 24hr portable
    • Sinus rhythm
    • Occasional isolated apcs
    • Frequent apc couplets
    • Paroxysmal atrial flutter-fibrillation
    • Occasional isolated vpcs
    • No long pause
  • 2023-04-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 10) / 53 = 81.13%
      • M-mode (Teichholz) = 81
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis and prominent posterior mitral annulus calcification with mild AR; mild MR.
      • Sinus tachycardia.
      • Ascites and pleural effusions.
  • 2023-04-27 ECG
    • Supraventricular tachycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2023-03-27 Ascites Tapping
    • Indication: Ascites
    • Symptoms: Abdominal fullness
    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000 ml straw color ascites was drained.
  • 2023-03-26 KUB
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-03-17 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
  • 2023-03-09 Patho - pancreas biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pancreas, FNB — Ductal adenocarcinoma, poorly differentiated
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of tan gray soft tissue, labeled pancreas, measuring up to 1.0 x 0.1 x 0.1 cm. All for section.
    • MICROSCOPIC EXAMINATION
      • The sections show a picture of adenocarcinoma, composed of nests, cords, and single pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and mucin secretion can be found. Tumor necrosis is present also.
  • 2023-03-08 Endoscopic Ultrasound
    • Diagnosis
      • Pancreatic body tumor, s/p CH-EUS & EUS/FNB
      • Pancreatic cystic tumor, body
      • Lymphadenopathy, periarotic area
    • Suggestion
      • Pursue pathology result
      • regular F/U
  • 2023-03-03 MR Cholangiography, MRCP
    • History
      • 20230226 CC: Abdominal Pain
      • 20230226 CT: A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases.
      • 20230227 CA199:582 U/mL (< 35), CEA: normal.
    • Findings:
      • There is a mass lesion in the pancreatic body and tail, 7.8 x 3.2 cm in size, showing hypointensity on T1WI, mild hyperintensity on T2WI and DWI. During contrast enhanced study, this lesion shows poor enhancement in arterial phase, portal venous phase, and delayed phase images.
        • Adenocarcinoma of the pancreatic body and tail (T3) is noted.
        • In addition, there is non-visualization of the splenic vein that is c/w tumor invasion.
      • There are five enlarged nodes in the celiac trunk, gastrohepatic ligament, and hepatoduodenal ligament that are c/w metastatic nodes (N2).
      • There are two masses 1.8 cm and 1.2 cm in S7 of the liver, shows mild hyperintensity on both T2WI and DWI, and poor enhancement.
        • Two liver metastases (M1) are noted.
      • There is massive ascites and multiple soft tissue nodules in the omentum that is c/w carcinomatosis (M1).
        • Please correlate with ascites cytology.
      • Bil. renal cysts (up to 6.6cm).
      • Hyperplasia of left adrenal gland.
    • IMP:
      • Adenocarcinoma of the pancreatic body and tail with liver metastases and carcinomatosis is suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for pancreatic cancer: T3 N2 M1, stage: IV
  • 2023-03-01 Patho - stomach biopsy
    • Duodenum, SDA to second portion, biopsy (A) — chronic inflammation and Brunner’s gland hyperplasia.
    • Stomach, Gastric ulcer, AW of lower antrum, s/p biopsy(B)— Chronic gastritis with intestinal metaplasia, H pylori NOT present
    • Stomach, Gastric erosion, PW of upper antrum, s/p biopsy(C)— ulcer with adenocarcinoma in situ (AIS), demonstrated with IHC stain of cytokeratin.
    • Stomach, Gastric lesion, GC of upper antrum, s/p biopsy(D)— Chronic gastritis, H pylori NOT present
  • 2023-02-27 Cell Block - Ascites
    • DIAGNOSIS:
      • SMEARS and CELLBLOCK: positive for malignancy; IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-).
    • GROSS DESCRIPTION:
      • 21 ml turbid
    • MICROSCOPIC DESCRIPTION:
      • SMEARS and CELLBLOCK: clusters of papillae with large nuclei and large cytoplasmic vacuole, a picture od adenocarcinoma.
      • IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-). The picture does NOT support gastric or pancreato-biliary origin.
  • 2023-02-26 CTA - abdomen
    • A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases. Massive ascites. Enlargement of prostate.

[MedRec]

  • 2023-03-22 SOAP Hemato-Oncology
    • S
      • This 78 year old man is a case of pancrease cancer with liver and peritoneal metastasis, stage IV, and gastric adenocarcinoma in situ.
      • The patient is currently unaware of the pancreatic cancer situation and only knows about the presence of a gastric tumor.
    • O
      • Lab
        • 2023-02-27 CA199 582.59 U/mL
        • 2023-02-27 CEA 1.82 ng/mL
      • Will on Abraxane plus gemcitabine
    • A
      • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
      • gastric adenocarcinoma in situ
    • P
      • admiited for port A insertion, family meeting, symptom control, discuss with palliative chemotherapy
      • refer to ER for ascites tapping and then admission for further management.
  • 2023-02-26 ~ 2023-03-09 POMR Gastroenterology and Hepatology
    • Discharge diagnosis
      • Suspicious pancreas cancer of body and tail with liver and peritoneum metastasesis T3N2M1, stage: IV, ECOG:2, status post paracentesis, status post endoscopic ultrasound-guided fine needle biospy on 2023/03/08
      • Gastric adenocarcinoma in situ
      • Gastric ulcer
      • Duodenal erosion
      • Colon polyps, cecum, proximal ascending and transverse colon, status post polypectomy
    • CC: abdominal distention for days
    • Prescription
      • spironolactone 25mg 2# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Through (sennoside 12mg) 1# HS
      • Curam (amoxicillin 875mg + clavulanic acid 125mg) 1# Q12H 3D

[chemotherapy]

  • 2023-04-24 - Nab-paclitaxel 80mg/m2 100mg 90min + gemcitabine 800mg/m2 800mg NS 100mL 30min (D1) dose reduced due to adverse reactions
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-04-03 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-03-27 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

[note]

hyperbilirubinemia - ref: 2023-05-05 UpToDate

  • An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. Unconjugated hyperbilirubinemia may be caused by:
    • Hemolysis
    • Extravasation of blood into tissue
    • Dyserythropoiesis
    • Stress situations (eg, sepsis) leading to increased production of bilirubin
    • Impaired hepatic bilirubin uptake
    • Impaired bilirubin conjugation
  • An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum. Conjugated hyperbilirubinemia may be caused by:
    • Biliary obstruction (eg, gallstones, pancreatic or biliary malignancy, AIDS cholangiopathy, parasites)
    • Viral hepatitis
    • Alcoholic hepatitis
    • Nonalcoholic steatohepatitis
    • Primary biliary cholangitis
    • Drugs and toxins
    • Ischemic hepatopathy
    • Liver infiltration
    • Inherited disorders (eg, Dubin-Johnson syndrome, Rotor syndrome, progressive familial intrahepatic cholestasis)
    • Total parenteral nutrition
    • Postoperative jaundice
    • Intrahepatic cholestasis of pregnancy
    • End-stage liver disease
    • Organ transplantation (eg, bone marrow, liver)

CA199, CEA - ref: 2023-05-05 ChatGPT

  • CA199: Elevated levels of CA199 can be associated with certain types of cancer, particularly pancreatic cancer. It may also be elevated in other malignancies such as colorectal, gastric, liver, and bile duct cancers.
  • CEA: CEA is a tumor marker, which means that its levels in the blood can become elevated in the presence of certain types of cancer, particularly colorectal cancer. However, CEA is not a specific marker, and its levels can also be elevated in other malignancies, such as lung, breast, stomach, pancreas, and ovarian cancers.

==========

2023-05-05

  • Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.

  • After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.

    • 2023-05-05 CA199 1087.93 U/mL
    • 2023-04-11 CA199 1161.06 U/mL
    • 2023-03-28 CA199 (Nuclear Medicine) 1151.56 U/ml
    • 2023-02-27 CA199 582.59 U/mL
    • 2023-05-05 CEA 5.54 ng/mL
    • 2023-04-11 CEA 3.78 ng/mL
    • 2023-03-28 CEA (Nuclear Medicine) 1.869 ng/ml
    • 2023-02-27 CEA 1.82 ng/mL
  • The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.

2023-05-02

[tube feeding]

  • As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.

  • For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.

  • As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.

2023-03-25

  • The patient has been diagnosed with stage IV pancreatic cancer with liver metastasis and peritoneal seeding, as well as in situ gastric adenocarcinoma. Although the patient is currently only aware of the stomach tumor, the pancreatic cancer is more advanced and should be prioritized for treatment.
  • It is possible that the modified FOLFIRINOX regimen could be considered for this patient, provided that the patient has an ECOG score of 0 or 1.

701300015

230505

[exam findings]

  • 2023-02-14 CT - abdomen
    • History and indication:
      • CEA = 89.37 ng/mL;
      • Adenocarcinoma of sigmoid colon with obstruction, cT3N1M0, stage IIIB post T-loop colosotmy (2021/06/16) status post laparoscopic sigmoidectomy on 2021/08/05, pT3N1bM0(3/14), G2, LVI(+), PNI(+), CRM(+), stage IIIB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation with colostomy. Recurrent tumors (up to 3.0cm) at LLQ.
      • Right renal stone (8mm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P colon operation with colostomy. Recurrent tumors (up to 3.0cm) at LLQ.
  • 2023-01-17 Colonoscopy
    • Findings
      • 10cm to previous operation site, ulcerative lesion but re-stenosis
      • 30cm from distal osteomy, then much old clot in colon and can not be removed.
    • Diagnosis
      • Anastomosis s/p transanal dissection but re-stenosis
    • Suggestion
      • OPD discuss treatment strategy.
  • 2022-12-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (56 - 11) / 56 = 80.34%
      • M-mode (Teichholz) = 81
    • Conclusion
      • Asymmetrical septal hypertrophy and apical hypertrophy, suspected non-obstructive type hypertrophic cardiomyopathy; indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
      • Normal LV and RV systolic function
      • Aortic valve sclerosis with mild AR.
      • Degenerative changes of mitral valve with mild to moderate MR; mild TR; moderate PR.
      • Prominent aortic root calcification with multiple protruding non-mobile atheromas (7-10 mm of thickness).
  • 2022-12-07 ECG
    • Sinus bradycardia
    • Left ventricular hypertrophy
    • Marked ST abnormality, possible anterior subendocardial injury
  • 2022-12-05 CT - abdomen
    • s/p colostomy with its orifice at RLQ.
    • s/p LAR with autosuture retention. No evidence of recurrent/residual tumor in the study.
  • 2022-08-24, -05-20 CT - abdomen
    • There is no evidence of tumor recurrence.
  • 2022-02-11, 2021-11-03 CT - abdomen
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P colostomy of right transverse colon.
    • There is no evidence of tumor recurrence.
  • 2021-05-05 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, sigmoid colon, laparoscopic sigmoidectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal: Free
      • Lymph node, mesocolic, dissection — Metastatic adenocarcinoma (3/14)
      • Pathology stage: pT3N1b(if cM0); AJCC stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic sigmoidectomy
      • Specimen site: sigmoid colon
      • Specimen size: 12 cm in length
      • Tumor size: 4x 3 cm
      • Tumor location: 3 cm away from the closest resection margin
      • Depth of invasion grossly:pericolorectal tissue
      • Mucosa elsewhere: Not remarkable
      • Representative section: A1-2:LNs, A3-6:tumor, B&C:cut-ends
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: pericolorectal tissue
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Present
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved
      • Lymph node metastasis, mesocolic: Positive (3/14)
      • Lymph node metastasis, IMA/SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT)
          • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN)
          • pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM)
          • N/A
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A.
  • 2021-08-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 33) / 126 = 73.81%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, LVH, grade 2 LV diastolic dysfunction
      • Mild AR, and PR, mild to moderate MR
  • 2021-06-21 Patho - colon biopsy
    • Colon, 18 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2021-06-13 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[MedRec]

  • 2023-02-22 SOAP Radiation Oncology
    • A: Adenocarcinoma, moderately differentiated, of the sigmoid colon, stage cT3N1bM0(IIIB), s/p Laparoscopic sigmoidectomy, stage pT3N1b(cM0), AJCC stage IIIB, with local recurrence, status during chemotherapy.
    • P: Radiotherapy is indicated for this patient with the following indicators: local recurrence
      • Goal: curative
      • Treatment target and volume: abdominal LLQ to pelvic area.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the abdominal LLQ to pelvic area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-03-07.
  • 2021-08-27 SOAP Hemato-Oncology
    • A: Adenocarcinoma of sigmoid colon with obstruction, cT3N1M0, stage IIIB post T-loop colosotmy (2021/06/16) status post laparoscopic sigmoidectomy on 2021/08/05, pT3N1bM0(3/14), G2, LVI(+), PNI(+), CRM(+), stage IIIB
    • P
      • F/U CEA (2021-09), CXR, CT, colonoscopy (2022-05)
      • suggest adjuvant chemotherapy, arrange chemotherpay
      • close colostomy 3 months later (2021-11)

[radiotherapy]

  • 2023-03-15 ~ 2023-04-20) - 4500cGy/25 fractions of the abdominal LLQ to pelvic area.

[chemotherapy]

  • 2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4555mg NS 250mL 46hr (FOLFIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-07 (FOLFIRI)

  • 2023-03-22 (FOLFIRI)

  • 2023-03-08 (FOLFIRI)

  • 2023-02-22 (FOLFIRI)

  • 2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-02-09 (FOLFOX)

  • 2022-01-26 (FOLFOX)

  • 2022-01-12 (FOLFOX)

  • 2021-12-29 (FOLFOX)

  • 2021-12-15 (FOLFOX)

  • 2021-12-01 (FOLFOX)

  • 2021-11-17 (FOLFOX)

  • 2021-11-03 (FOLFOX)

  • 2021-10-20 (FOLFOX)

  • 2021-10-01 (FOLFOX)

  • 2021-09-09 (FOLFOX)

[assessment]

  • No medication reconciliation issues have been identified for this patient.

  • The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.

700279535

230504

[allergy]

  • NKDA

[family history]

  • Aunt: DM
  • Uncle: Colon ca
  • Father: heart disease, ESRD under hemodialysis

[exam findings]

  • 2023-05-03 Endoscopic Ultrasound, EUS
    • Pancreatic body cancer, s/p CH-EUS & EUS/FNB (B)
    • Hepatic tumors, s/p CH-EUS & EUS/FNB (A)
    • Lymphadenopathy
  • 2023-05-02, -04-27 CXR
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-04-17 CT - abdomen
    • Indication:
      • HBV f/u, elevated CEA and CA-199
      • multiple liver tumor, suspicious pancreatic tumor with liver metastasis.
    • Abdominal CT with and without enhancement revealed:
      • Soft tissue mass at pancreatic body/neck junction measuring 2.9cm in largest dimension is found. Pancreatic cancer is considered. The distal pancreatic duct is obstructed with dilatation.
      • Low density lesions scattered at both lobes of liver measuring 2.8cm are found. Liver meta is considered.
    • IMP: Pancreatic cancer with liver meta.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-04-15 SONO - abdomen
    • Diagnosis
      • Liver tumors, favor metastatic tumors
      • pancreatic tumor
      • mild fatty liver, suspected mild liver parenchyma disease
    • Suggestion
      • 4 phase CT or dynamic MRI study
  • 2022-10-08 SONO - abdomen
    • Diagnosis
      • Liver tumor favor hemangioma
      • mild fatty liver, suspected mild liver parenchyma disease
      • fatty infiltration of pancreas
      • suspected pancreatic lesion: hypoechoic
    • Suggestion
      • suggest further image study such as CT scan or MRI or EUS
  • 2022-03-26 SONO - abdomen
    • Diagnosis
      • Liver tumor favor hemangioma
      • mild fatty liver, suspected mild liver parenchyma disease
      • some parts of pancreas not shown
    • Suggestion
      • Regular F/U

[consultation]

  • 2023-05-04 Dermatology
    • Q
      • Patient was 50 years old men, history of HBV carrier regular follow up.
      • For suspect pancreatic cancer with liver meta. cT2N0M1, This time, admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion.
      • He has psoriasis more than ten years, we need your consultation for evaluation.

[MedRec]

  • 2023-04-19 SOAP Hemato-Oncology
    • A: Suspect pancreatic cancer with liver meta. cT2N0M1
    • P: Admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion

701103011

230504

[diagnosis] - 2023-05-06 discharge note

  • Gastric cancer with pancreas, spleen and liver metstases, stage IV s/p oral chemotherapy with UFUR from 2022/08/16 to 2023/05/02 with lung metastasis s/p chemotherapy with CapOx at SYSCC s/p chemotherapy with FOLFOX (Oxalip 65mg/m2, LV 400mg/m2, 5FU 400mg/m2, 5FU 2400mg/m2) from 2023/05/03
  • Chronic viral hepatitis B without delta-agent

[MedRec]

  • 2023-04-19 SOAP Hemato-Oncology
    • S:
      • Hx of gastric cancer s/p C/T with UFUR
    • O:
      • 2018/01/30 Surgical pathology Level IV
        • Stomach, antrum and body, AW, LC, PW, biopsy — modertaely differentiated adenocarcinoma
    • P:
      • Admssion for checking HBV, HCV, CBC/DC, Biomchemistry and AFP/CA125/CA199/CEA, FOLFOX

[chemotherapy]

  • 2023-05-03 - oxaliplatin 65mg/m2 90mg D5W 250mL 6hr + leucovorin 400mg/m2 550mg NS 500mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFOX, Oxa long infusion to prevent allergy)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

[assessment]

  • The patient received the FOLFOX regimen on 2023-05-03, with a reduced dose of oxaliplatin (85mg/m2 to 65mg/m2) and an extended infusion time (from 2 hours to 6 hours), as well as the addition of famotidine 20mg as premedication. As of now, no significant adverse reactions have been observed.

701158070

230504

[exam findings]

  • 2023-05-02 CT - abdomen
    • Without contrast enhancement CT of abdomen shows:
      • Presence of splenomegaly. Focal fluid density at its dorsal part, r/o infarct.
      • Right renal stone. Mild dilatation of right urotract.
      • Suspect increased density of bony structures.
    • Impression
      • Splenomegaly with suspected splenic infarct
      • Increased density of bony structures

[assessment]

  • Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.

    • 2023-05-04 WBC 237.23 x10^3/uL
    • 2023-05-03 WBC 295.36 x10^3/uL
    • 2023-05-02 WBC 412.38 x10^3/uL
    • 2023-04-24 WBC 364.18 x10^3/uL
    • 2023-05-04 Blast 1.0 %
    • 2023-05-03 Blast 1.0 %
    • 2023-05-02 Blast 11.0 %
  • Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as

    • Pulmonary signs and symptoms: dyspnea, hypoxia with or without diffuse interstitial or alveolar infiltrates on imaging studies. Pulse oximetry provides a more accurate assessment of O2 saturation in this setting.
    • Neurologic signs and symptoms: visual changes, headache, dizziness, tinnitus, gait instability, confusion, somnolence, and occasionally coma.
  • Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.

  • Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).

701476884

230504

[lab data]

  • 2023-05-03 Anti-HBc Reactive
  • 2023-05-03 Anti-HBc-Value 8.55 S/CO

[exam findings]

  • 2023-04-14 Patho - pancreas biopsy
    • Pancreas, EUS FNA/B — Ductal adeocarcinoma, moderately differentiated
    • The sections show a picture of ductal adenocarcinoma, moderately differentiated, composed of nests, cords and single large pleomorphic neoplastic cells in fibrous stroma. Focal tubular formation and mucin secretion can be found.
  • 2023-04-14 Endoscopic Ultrasound, EUS
    • Diagnosis
      • Pancreatic head cancer s/p CH-EUS & EUS/FNB
      • MPD and CBD dilatation
      • Reflux esophagitis
    • Suggestion
      • Follow up pathology
  • 2023-04-14 SONO - abdomen
    • Diagnosis
      • Pancreatic tumor favor cancer
      • Dilated CBD
      • GB polyp
      • Parenchymal liver disease
    • Suggestion
      • further investigation
  • 2023-04-07 CT - abdomen
    • Indication: 2023/03/28 abdominal pain off and on for several months, BW loss (+)
      • PI: appetite: good
      • PHx: HTN (+), HBV carrier
    • Findings:
      • There is a well-defined poor enhancing mass measuring 4.5 x 3.4 cm in the pancreatic neck, causing upstream pancreatic duct dilatation. This mass shows direct attachment and narrowing of the trifurcation of portal vein, superior mesenteric vein, and splenic vein that is c/w portal vein invasion and encasement.
        • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
        • Please correlate with CA199 and EUS.
        • In addition, there are four lymph nodes in gastrohepatic ligament and hepatoduodenal ligament that are c/w metastatic nodes (N2).
      • There is mild dilatation of IHDs and CHD that is due to upper described pancreatic neck mass with directly invasion the CHD.
      • There is an ill-defined equivocal faint poor enhancing area in S7 of the liver that may be flow artifact.
        • The differential diagnosis includes metastasis.
        • Please correlate with sonography and MRI.
      • There is a renal stone 0.9 cm in left lower pole and another tiny renal stone in left upper pole.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

  • 2023-04-26 SOAP Hemato-Oncology
    • P
      • Family request admission
  • 2023-04-25 SOAP Hemato-Oncology
    • O
      • 2023/04/14 Fine needle aspiration cytology - Pancreatic aspiration (Pancereas) — Malignancy
      • 2023/04/14 HBsAg = Reactive;
      • 2023/04/14 HBsAg (Value) = 4773.38 S/CO;
      • 2023/04/14 2023/04/14 Anti-HCV = Nonreactive;
      • 2023/04/14 2023/04/14 CEA = 11.25 ng/mL;
      • 2023/04/14 2023/04/14 CA199 = 2507.98 U/mL;
      • 2023/04/14 planning: neoadjuvant C/T first
      • 2023/04/14 arrange Port-A
    • A
      • May try OPD C/T with biweekly FOLFIRINOX.

[note]

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

[chemotherapy]

  • 2023-05-02 - irinotecan 120mg/m2 200mg D5W 250mL 90min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + NS 250mL + aprepitant 125mg D1-3

[assessment]

  • This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.

  • 2023-05-03 Anti-HBc Reactive
    2023-05-03 Anti-HBc-Value 8.55 S/CO

701432621

230503

[diagnosis] - 2023-05-02 admission note

  • Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
  • Iron deficiency anemia, unspecified

[exam findings]

  • 2022-12-26 PET
    • Increased FDG uptake in several celiac lymph nodes, gastric cancer with regional lymph nodes involvement should be considered, suggesting further investigation.
    • Increased FDG uptake in the right lobe of the liver, highly suspected gastric cancer with distant metastases.
    • Increased FDG uptake in the right nasopharynx, the nature is to be determined (inflammation/infection process or other nature ?), suggesting further investigation.
    • Gastric cancer s/p treatment with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-11-28 CT - abdomen
    • Indication: Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
    • Abdominal CT with and without enhancement revealed:
      • s/p gastrectomy.
      • Hepatic tumors at S7 about 3.2cm and S6 about 2.9cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2022-07-19, the tumors are enlarged.
    • Imp:
      • s/p gastrectomy.
      • Liver meta. In progression.
  • 2022-09-06 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Tubular adenocarcinoma
      • Margins, bilateral cutting ends and radial, total gastrectomy — Free of tumor invasion
      • Lymph nodes, LN dissection — Metastatic adenocarcinoma (2/40)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN1(cM0), stage IIIA
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, omentum
      • Specimen size: (a) Stomach: 36 cm long greater curvature and 19 cm along lesser curvature, (b) Omentum: 35 x 20 x 5.0 cm
      • Number of lesions: Solitary
      • Tumor site: Middle body, anterior wall, lesser curvature, 6.0 cm from distal margin
      • Tumor size: 9.2 x 7.5 x 3.5 cm
      • Tumor configuration: Fungating tumor with central ulceration
      • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A9= tumor, A10= lesser curvature LN, B= LN 1, C= LN 2, D= LN 3, E1-E2= LN 4, F= LN 5, G= LN 6, H1-H2= LN 7,8,9,11,12, I= LN 10, J= LN 14v, K1-K3= omentum
    • MICROSCOPIC EXAMINATION
      • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
      • Histologic grade: Moderately differentiated (G2)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 3 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic adenocarcinoma (2/40)
        • 1/1 (lesser curvature LN), 0/2 (LN 1), 0/3 (LN 2), 1/4 (LN 3), 0/6 (LN 4), 0 (LN 5), 0/8 (LN 6), 0/13 (LN 7, 8, 9, 11, 12), 0/3 (LN 10), 0 (LN14v) (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Omentum: Free of tumor invasion
      • Additional pathologic findings: Non-atrophic chronic gastritis
      • Pathologic Staging: pT4aN1(cM0), stage IIIA
      • IHC (S2022-12775): HER2 (Positive, score= 3+)
  • 2022-08-30 MRI - liver, spleen
    • History and indication: Gastric cancer, suspect liver metastasis
    • With and without contrast MRI of liver revealed:
      • Gastric cancer with peritoneal seeding and LNs metastases.
      • Two enhancing tumors (2.7cm, 2.9cm) at S5 and S7 of liver without venous wash out pattern. Another small enhancing nodules at both hepatic lobes.
      • Tiny liver and renal cysts.
    • IMP:
      • Gastric cancer with peritoneal seeding and LNs metastases.
      • Suspected liver hemangiomas.
  • 2022-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (205 - 59) / 205 = 71.22%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis.
      • (suboptimal parasternal echo window barrel chest)
  • 2022-08-04 Patho - stomach biopsy
    • Stomach, AW side of mid body, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
    • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Positive (3+).
  • 2022-08-04 Esophagogastroduodenoscopy, EGD
    • Highly suspected gastric malignancy, s/p biopsy
    • Reflux esophagitis LA grade A
    • Superficial gastritis
  • 2022-07-19 CT - abdomen
    • History: easy hunger(+),
      • weight loss 72 (before) -> 68.5 (2022/04) -> 63kg (2022/06)
      • 2022/07/07 exertional dyspnea recent months.
      • 2022/07/18 s/p one week iron supplement, no adverse effect
    • Indication: Abnormal weight loss
    • Findings:
      • There is lobulated circumferrential irregular wall thickening at the stomach fundus and body, measuring 2.8 cm in the maximal wall thickness (T3).
        • Lymphoma is highly suspected.
        • The differential diagnosis include signet ring cell carcinoma.
        • Please correlate with gastroscopy.
        • In addition, There are ten enlarged nodes in the adjacent omentum, gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N3a).
      • There are two ill-defined homogeneous enhancing lesion measuring 2.5 cm in S7 and 2.2 cm in S5 of the liver at arterial phase images but isodensity (no contrast washout) in portal venous phase and delayed phase images.
        • The differential diagnosis include Atypical hemangioma, FNH and metastasis. Please correlate with MRI.
      • There are several small poor enhancing lesions on both hepatic lobes, the largest one 5 mm, that may be cysts?
        • However, they are too small to chracterize.
      • Please correlate with sonography.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N3a (N_value) M:M0 (M_value) STAGE:III(Stage_value)
  • 2022-07-12 SONO - abdomen
    • Diagnosis
      • Liver tumors, S5 and S7
      • Possible small para-aortic pymph nodes
    • Suggestion
      • 4 phase CT or dynamic MRI study

[consultation]

  • 2022-08-30 Gastroenterology
    • Q
      • This is a 61 year-old male, without underlying disease, admitted because of body weight loss 5 kg in 3months.
      • Panendoscope revealed one massive ulcerative tumor at gastric body. Pathology showed adenocarcinoma.
      • Abdominal CT also revealed 2 Liver tumor, differential diagnosis included atypical hemangioma, FNH and metastasis.
      • We need your expertise for TPN support
    • A
      • A case of gastric cancer who request pre-op nutrition support.
        • General appearance: ill looking
        • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (-), Poor digestion (-), BW loss (+, 5kg/3Ms) , stool (+), Bowel sound (-)
        • Feeding: as tolerance
        • Allergy: NKA
        • Nutrition assessment:
          • BH 176cm BW 64.5kg
          • IBW 68.2kg 95%IBW BMI 20.8
          • BEE 1421kcal TEE 2217kcal
        • Lab data: Alb 3.7 K 4.2 TP 7.0 BS 98
        • According to the patient’s present conditions, parenteral nutrition plus enteral feeding (as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN Use Suggestion:
        • DC SMOFkabiven peri 1440ml QD (KCL 10ml)
        • SMOFkabiven central 1477ml QD, 61.5ml/hr
        • Lyo-Povigent 4ml/QD (add in TPN) (when out of stock, switch to adding B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
        • Addaven 10ml/QD(add in TPN)
      • Items to monitor during PN (Parenteral Nutrition) use:
        • TPN is used with single route, do not mix with other medications besides TPN drugs.
        • Check BW QW5 and record I/O Q8H
        • Check one touch Q6H x 2days, if stable QD check
        • Please control BS <200 mg/dl with RI sliding scale
        • QW1 check CBC/DC
        • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
        • When TPN is insufficient, substitute with YF5 or D10W
        • On the day of surgery, temporarily hold the lipid emulsion
        • Kabiven requires daily pump set replacement

[MedRec]

  • 2022-12-27 SOAP Hemato-Oncology
    • S
      • PET scan (12/26 22):
        • several celiac LNs, gastric CA wt regional LNs involvement should be considered.
        • Lesion at R lobe of the liver, R/I mets. Imp: Gastric CA s/p Tx wt suspected regional LNs & liver mets, cTxN2M1, stage IVB (AJCC 8th ed.).
      • Liver mets poved by PET scan post post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (12/27 22).
      • Adm 2 wk later on 1/9 23 for #1 2nd line palliative C/T wt FOLFIRI IV Q2W x 6.
  • 2022-09-24 SOAP Hemato-Oncology
    • S
      • adjuvant C/T wt mFOLFOX IV Q2W x 12 & post-Op adjuvant CCRT (9/24 22).
      • HBsAg, anti-HCV (7/26 22): negative. will do anti-HBc (9/24 22).
      • will consult Dr in Radiation Oncology for R/T to gastric tumor bed. (9/24 22).
      • will give post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (9/24 22).
      • Adm 1 wk later on 10/3 22 for #1 post-Op adjuvant C/T wt mFOLFOX ( self-paid ) IV Q2W x 6.
    • A
      • Gastric CA, pT4aN1 (2/40) cM0, stage IIIA, s/p total gastrectomy on 9/5 22
  • 2022-08-11 SOAP Gastroenterology and Hepatology
    • Assessment
      • Consider gastric cancer with LN metastasis
      • the liver tumor may be not metastasis but may arrange MRI to check if it was hemangioma or FNH.

[surgical operation]

  • 2022-09-05
    • Surgery
      • Total gastrectomy with lymphadenectomy of station 1 to 12a and 14v.
      • Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA.
    • Finding
      • 8x7x4 cm tumor at middle body anterior wall of stomach invaded the serosa.
      • Lymph node enlargement at station 3.
      • Scarring around gastroduodenal junction.
      • No ascites, no peritoneal seeding and no liver surface metastasis.
      • cT4aN2M0 stage III.

[chemoimmunotherapy]

  • 2023-05-02 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4090mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-03-17 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - irinotecan 170mg/m2 285mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2022-12-23 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-09 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-25 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-10 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-24 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-05 - oxaliplatin 70mg/m2 100mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

  • The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.

  • A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.

  • The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.

  • After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.

  • The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).

  • A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.

2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.

The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.

The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700758055

230502

[diagnosis]

  • Malignant neoplasm of left renal pelvis, small cell neuroendocrine carcinoma, ypT4NxcM0, ypStage IV

[past history]

  • hypertension
  • type II diabetes mellitus
  • dyslipidemia
  • insomnia
  • OP history: appendectomy 30 years ago, left laparoscopic nephroureterectomy on 2021-08-30.      

[family history]

  • Father - CVA.
  • Mother - hepatoma.

[exam findings]

  • 2023-04-29 CT - abdomen
    • Indication: Small cell neuroendocrine carcinoma of left kidney, ypT4NxcM0, ypStage IV s/p chemotherapy with Topotecan from 2023/01/16
    • With and without contrast enhancement CT of abdomen shows:
    • Imaging Protocol: 5mm slice thickness, axial scan and coronal reconstruction
      • s/p left nephrectomy.
      • Para-aortic mass lesions, in progression.
      • Enlarged lymph nodes along bilateral iliac vessels.
      • Small nodular lesions, up to 0.8cm, in liver.
      • No ascites or extraluminal free air.
      • No bony destructive lesion on these images.
    • Impression
      • s/p left nephrectomy
      • Para-aortic mass lesion, in progression; DDx: recurrent tumor, lymph node metastasis
      • Suspect liver metastasis
  • 2023-02-06, -01-23, -01-16 Standing KUB
    • Fecal material store in the colon.
  • 2023-01-27 PD-L1 IHC 28-8
    • S2021-11516A9, renal pelvic cancer
    • Tumor cell (TC) staining assessment: >= 1% and <5%
    • Percentage of PD-L1 expressing tumor cells (TC):1%
  • 2023-01-27 PD-L1 IHC 22C3
    • Combined Positive Score (CPS) assessment: >=1 and <10
    • Combined Positive Score (CPS) : 2
  • 2023-01-05 CT - abdomen
    • History and indication: renal pelvis tumor, s/p OP
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P left nephrectomy. Soft tissues in paraaortic region and pelvic cavity (progression).
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P left nephrectomy. Progression of tumor recurrence.
  • 2022-11-09 Gynecologic ultrasonography
    • EM: 3.7mm
  • 2022-11-02 KUB
    • Disc space narrowing at L4/5.
  • 2022-10-07 CT - abdomen
    • History:
      • 20210510 CT: left renal pelvis UC with LN metastases, cT3N1M1
      • 20210830 left nephrectomy: pT4Nx (if cM0), pstage:IV
      • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
        • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
      • Findings:
        • S/P left nephrectomy.
          • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
            • In addition, Prior CT idenified enlarged nodes in right para-cava space are noted again, stable in size.
            • Follow up is indicated.
        • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
      • IMP:
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
  • 2022-09-23 Tc-99m MDP whole body bone scan
    • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, wrists, hips, knees and feet, compatible with benign joint lesions.
  • 2022-07-22 CT - abdomen
    • Findings:
      • S/P left nephrectomy.
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
  • 2022-04-07 CT - abdomen
    • Findings
      • S/P left nephrectomy. Soft tissues in paraaortic region.
    • IMP:
      • S/P left nephrectomy. Soft tissues in paraaortic region suspected tumor recurrence.
  • 2022-01-05 CT - abdomen
    • Findings:
      • S/P left nephrectomy.
        • There is lobulated soft tissue lesions in left para-aortic space and left common iliac chain that may be metastatic nodes.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Metastatic nodes in left para-aortic space and left common iliac chain are suspected.
  • 2021-09-06 Cystography
    • Cystography via foley catheter administration revealed:
      • The bladder capacity is about 100cc.
      • No evidence of contrast medium leakage.
  • 2021-08-31 Patho - kidney partial/total resection
    • Diagnosis
      • A
        • Kidney, left pelvis, laparoscopic nephroureterectomy — Small cell neuroendocrine carcinoma, s/p chemotheraphy, AJCC 8th edition: ypStage IV, ypT4Nx(if cM0)
        • Ureter, left, nephrectomy — Negative for malignancy
        • Blood vessel, left, nephrectomy — Negative for malignancy
        • Capsule, left kidney, nephrectomy — Small cell neuroendocrine carcinoma, by direct invasion
      • B: Soft tissue, labeled as “para-aortic lymph node”, excision — Negative for malignancy (0/0)
    • Gross Description
      • Procedure: laparoscopic nephroureterectomy
      • Laterality: Left
      • Specimen size:
        • Kidney: 7.4 x 4.0 x 2.5 cm; 60 gm
        • Ureter: 15.9 cm in length and 0.4 cm in maximal diameter
        • Adrenal gland: not received
      • Tumor size: 1.5 x 1.5 x 1.2 cm
      • Tumor site: Renal pelvis, parenchyma, hilar soft tissue, and invasion through the capsule to the perinephric fat
      • Tumor appearance: fibrosis
      • Tumor focality: Unifocal
      • A piece of tissue, labeled as “para-aortic lymph node”, is received.
      • Sections are taken and labeled as: A1: ureteral resection margin; A2: capsule; A3: blood vessel; A4: kidney, non-tumor; A5: ureter; A6-7: hilar soft tissue; A8-13: tumor (A11: with upper ureter); A14-16: tumor with capsule and the perinephric fat; B: para-aortic lymph node.
    • Microscopic Description
      • Histological type:: Small cell (neuroendocrine) carcinoma;
        • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), Chromogranin A(focal +), CD10(-), PAX8(-), CK5/6(-), and GATA3(-).
        • The Ki-67 is < 5%.
      • Histological grade: poorly differentiated
      • Pathological staging (pTNM, AJCC 8th edition):
        • TNM Descriptors: (required only if applicable) (select all that apply): y (posttreatment)
          • Primary tumor (pT): pT4: Tumor invades adjacent organs, or through the kidney into the perinephric fat
          • Regional lymph nodes (pN): pNx: Regional lymph node cannot be assessed
          • Distant metastasis (pM): (required only if confirmed pathologically in this case): if cM0
      • Section margins: Uninvolved by invasive carcinoma; 15.9 cm away from the ureteral resection margin; 0.8 cm away from the hilar soft tissue resection margin; 0.5 cm away from the perinephric fat resection margin.
      • Lymphovascular invasion: Present
      • Pathologic findings in ipsilateral nonneoplastic kidney: lymphocytic infiltration and fibrosis
      • Additional pathologic findings: No lymph node is seen in “para-aortic lymph node” specimen.
      • Perineural invasion is seen.
  • 2021-08-29 CXR
    • Intimal calcification of thoracic aorta.
  • 2021-08-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 32) / 79 = 59.49%
      • M-mode (Teichholz) = 59
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA; septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Mild MR and trivial TR
    • Preserved RV systolic function
  • 2021-08-10 CT - abdomen
    • Clinical history: 76 y/o female patient with right renal pelvis UC with lymph node metastasis, cT3N1M1, PD-L1 all negative.
    • WITHOUT contrast enhancement CT: ABD — whole abdomen, pelvis:
      • Regression of left renal tumor and paraaortic soft tissue, could be due to regression of renal pelvis UC with lymph nodes metastasis.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Left renal UC with lymph nodes metastasis, regression.
  • 2021-06-09 PD-L1 (SP142)
    • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma
      • PD-L1 Expression: <5% IC
      • Scores: Immune cells (IC): <1%; Tumor cells (TC): 0%
  • 2021-05-29 KUB
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Mild lumbar spondylosis.
  • 2021-05-29 Bladder Sonography
    • PVR 10.7mL
  • 2021-05-24 Patho - kidney biopsy
    • Kidney, left, CT guided biopsy — Compatible with invasive urothelial carcinoma, high-grade
    • The sections show sheets of spindle to oval-shaped pleomorphic neoplastic cells with hyperchromatic nuclei, embedded in fibrous stroma. Severe crush artifact is present.
    • IHC: GATA3(focal +), CK5/6(focal +), PAX8(-), CD10(focal +), and Vimentin(focal +).
    • The finding is compatible with high-grade invasive urothelial carcinoma. Renal cell carcinoma is less likely.
  • 2021-05-24 Body fluid cytology - urine
    • Diagnosis: Atypia
    • Macroscopic examination: L’t ureter: 6 cc colorless clear urine by URS
    • Microscopic examination: Smears show a few urothelial cells with mild enlarged nuclei. No morphologic evidence of high grade, but low grade urothelial carcinoma can not be excluded completely due to cytologic limitation. Please correlate with the biopsy result for conclusive diagnosis.
  • 2021-05-23 ECG
    • Normal sinus rhythm
    • Cannot rule out Inferior infarct, age undetermined
    • T wave abnormality, consider anterior ischemia

[chemotherapy]

  • 2023-03-31 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
  • 2023-03-06 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
  • 2023-02-13 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2023-01-18 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3 (topotecan 1.5mg/m2 adjusted to 0.75mg/m2 due to impaired renal function)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2023-01-16 - topotecan 1.5mg/m2 2mg NS 50mL 30min D1-5
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-5
  • 2022-07-21 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
  • 2022-06-23 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
  • 2022-05-26
  • 2022-04-28
  • 2022-01-04
  • 2021-12-07
  • 2021-10-28
  • 2021-10-05 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3
  • 2021-08-10 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-08-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-07-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-07-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-22 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-01 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)

==========

2023-05-02

  • On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.

  • The patient’s renal function improved according to the most recent lab values.

    • 2023-04-28 Creatinine 0.92 mg/dL
    • 2023-04-19 Creatinine 1.46 mg/dL
    • 2023-04-11 Creatinine 1.44 mg/dL
    • 2023-03-28 Creatinine 1.47 mg/dL
    • 2023-04-28 eGFR 62.91
    • 2023-04-19 eGFR 36.92
    • 2023-04-11 eGFR 37.52
    • 2023-03-28 eGFR 36.63
  • If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.

2023-03-07

  • This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.

    • 2023-03-02 WBC 5.87 x10^3/uL

    • 2023-02-23 WBC 12.24 x10^3/uL

    • 2023-02-16 WBC 3.07 x10^3/uL

    • 2023-02-13 WBC 4.44 x10^3/uL

    • 2023-02-09 WBC 22.96 x10^3/uL

    • 2023-02-06 WBC 2.70 x10^3/uL

    • 2023-02-03 WBC 2.09 x10^3/uL

    • 2023-02-01 WBC 2.32 x10^3/uL

    • 2023-01-30 WBC 1.66 x10^3/uL

    • 2023-01-27 WBC 0.71 x10^3/uL

    • 2023-01-26 WBC 0.70 x10^3/uL

    • 2023-01-22 WBC 2.41 x10^3/uL

    • 2023-01-16 WBC 5.05 x10^3/uL

    • 2023-03-02 PLT 234 x10^3/uL

    • 2023-02-23 PLT 109 x10^3/uL

    • 2023-02-16 PLT 275 x10^3/uL

    • 2023-02-13 PLT 308 x10^3/uL

    • 2023-02-09 PLT 270 x10^3/uL

    • 2023-02-06 PLT 123 x10^3/uL

    • 2023-02-03 PLT 65 x10^3/uL

    • 2023-02-01 PLT 47 x10^3/uL

    • 2023-01-30 PLT 50 x10^3/uL

    • 2023-01-27 PLT 154 x10^3/uL

    • 2023-01-26 PLT 38 x10^3/uL

    • 2023-01-22 PLT 155 x10^3/uL

    • 2023-01-16 PLT 312 x10^3/uL

2023-02-14

  • S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:

    • [28-8]
      • Tumor cell (TC) staining assessment: >= 1% and <5%
      • Percentage of PD-L1 expressing tumor cells (TC): 1%
    • [22C3]
      • Combined Positive Score (CPS) assessment: >=1 and <10
      • Combined Positive Score (CPS): 2
  • PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.

  • In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.

2023-01-27

  • 2023-01-27 WBC 710 cells/uL, Neutrophil 5%, ANC < 500 cells/uL, grade 4 neutropenia developed, Granocyte (lenograstim) and Cefim (cefepime) have been initialized since 2023-01-26 morning. Since 2023-01-26 19:00, the patient’s body temperature has not exceeded 37.5 degrees Celsius.
  • During the period of 2023-01-24 to 26, there were 3, 2, 3 bowel movements, and Nako No.5 (electrolyte supplement) was administered appropriately.
  • As far as the active prescription is concerned, there is no problem.

700509855

230428

[diagnosis] - 2023-04-27 admission note

  • Malignant neoplasm of stomach, unspecified
  • Secondary malignant neoplasm of right ovary
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Essential (primary) hypertension

[exam findings]

  • 2023-04-27 KUB
    • S/P port-A insertion.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Lumbar spondylosis.
    • T12 and L1 compression fractures.
  • 2023-04-27 CXR
    • Emphysematous change of bilateral lungs.
    • No cardiomegaly.
    • Thoracolumbar spondylosis.
    • R/O old fractures at left ribs.
  • 2023-04-24 Cytology - ascites
    • 17 cc yellow turbid ascites — Atypia (before IP C/T)
  • 2023-04-20 CT - chest
    • Indication: GIST with peritoneal and ovarian metastasis, stage IV s/p HIPEC and operationr/o other metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified dot at subpleural space of right lower lobe is found measuring 0.24cm in largest dimension.
        • Bilateral apical pleura fibrosis is found.
        • Calcified coronary arteries is found.
        • There is moderate bilateral pleural effusion.
      • Visible abdomen:
        • Moderate ascites formation is found. Dirty appearance of the mesentery is found. Cancerous peritonitis is considered. In comparison with CT dated on 2022-12-13, the lesion is stationary.
        • Bilateral hydronephrosis and hydroureter is found. Stable.
        • Dilatation of the IHDs and CBD is noted.
        • The intestines are dilated.
    • IMp:
      • Moderate bilateral pleural effuison and massive ascites with cancerous peritonitis
      • Bilateral hydronephrosis and hydroureter. Stable
      • Dilatation of the IHDs and CBD
  • 2023-04-19 Tc-99m MDP bone scan with SPECT
    • The hot spot in the lateral aspect of a left lower rib (10th rib ?) comes to faint compared with the previous study on 2023-01-04, probably post-traumatic change.
    • However, there are several new lesions of increased tracer uptake in the posterior aspect of the left rib cage and in three lower T- and upper-L-spine, bone metastasis and/or pathological fracture should be considered, suggesting MRI for investigation.
    • Suspected benign lesions in the maxilla, both rib cages, bilateral shoulders, and hips.
  • 2023-04-17 ECG
    • Low voltage QRS
  • 2023-03-27 L-spine Ap + Lat (including sacrum)
    • Degeneration and spondylosis of L-S spine.
    • Atherosclerosis of the aorta.
  • 2023-03-27 Peripheral Vascular Test - vein, lower limbs
    • Conclusion
      • No evidence of venous thrombosis at bilateral lower limbs venous systems.
      • No significant venous refluxes at biateral lower limbs venous systems.
      • Tissue edema at bilateral lower legs.
      • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2023-03-10 ECG
    • Sinus rhythm with Premature atrial complexes
  • 2023-02-16 SONO - abdomen
    • Hepatic cysts
    • Bil hydronephrosis
    • Ascies, mild
    • CBD dilatation
    • Rt renal cyst
  • 2023-01-13 Patho - peritoneum biopsy
    • DIAGNOSIS:
      • Peritoneum, biopsy — metastatic adenocarcinoma, consistent with gastric origin
      • Soft tissue, right pelvic tumor, biopsy — metastatic adenocarcinoma, consistent with gastric origin
      • Ovary, right, oophorectomy — Metastatic adenocarcinoma, consistent with gastric origin — Serous cystadenoma
      • Fallopian tube, right, salpingectomy — Metastatic adenocarcinoma, consistent with gastric origin
    • MICROSCOPIC DESCRIPTION:
      • Section shows fibroadipose tissue with infiltration of signet-ring cells.
        • The immunohistochemical stain of CK is positive. Metastatic adenocarcinoma from stomach is favored. Please correlate with the clinical presentaion.
      • Sections show ovary with metastatic glandular and signet-ring tumor cells. An ovarian cyst lined by a single layer of benign serous epithelium is also seen. The fallopian tube reveals transmural invasion of glandular and signet-ring tumor cells. Lymphovascular and perineural invasion is seen.
        • The immunohistochemical stains reveal CK7(+), CK20(+), CDX2(+), and PAX8(-). The results are consistent with metastatic adenocarcinoma from stomach.
  • 2023-01-04 Tc-99m MDP bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the lateral aspect of a left lower rib (10th rib ?), faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, and S-I joints, in whole body survey. Radiotracer retention in bilateral kidneys was noted.
    • IMPRESSION:
      • A hot spot in a left lower rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, and S-I joints.
      • Radiotracer retention in bilateral kidneys, the nature is to be determined, suggesting further evaluation.
  • 2022-12-29 Cell block
    • Clinical Finding: ovary cancer
    • 50cc, turbid, orange — Positive for malignancy
    • Smears and cell block show atypical neoplastic cells with abundant clear cytoplasm and pushing nuclei with signet ring-like picture.
  • 2022-12-28 CT - chest
    • Indication: moderate right pneumothorax.
    • Findings
      • lungs: dependent partial atelectasis of RLL and band subsegmental atelectasis of RUL. tiny granuloma (3mm) at LLL and two tiny granulomas (3mm) at RLL. two noncalcified solid nodules (up to 6mm) and several faing lobular GGOs at LUL. suspicious cylindrical bronchiectasis at LLL.
      • Mediastinum and hila: no enlarged LN or mass. mild calcified plaques of the LAD and LCX coronary arteries.
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers..
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents:
        • massive ascites and soft tissue densities in the omentum, along peritoneum.
        • a ulcerative tumor at posterior wall of the body of stomach.
        • Lt heaptic cyst 7cm, Rt renal cyst 1.6cm, and bilateral hydronephrosis.
        • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, and pancreas.
        • no enlarged lymph node.
      • Visualized bones: unremarkable. .
    • Impression:
      • moderate right pneumothorax. tiny granulomas in RLL and LLL and small nodules in LUL (favor benign nodules) of lung.
      • gastric cancer with massive ascites and peritoneal carcinomatosis
  • 2022-12-27 Patho - stomach biopsy (Y1)
    • Stomach, upper body, PW, biopsy — Adenocarcinoma, signet ring-like, non-cohesive.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and signet ring-like neoplastic cells.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      • ADDENDUM: IHC stains: PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2022-12-26 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Advanced gastric cancer, type III, upper body, PW, s/p biopsy
  • 2022-12-26 Colonoscopy
    • The scope had been inserted up 20 cm above anal verge, probably at level of rectal-sigmoidal juncction. Futher insertion is difficult because acute angle. Thus, the exam was stopped
    • Diagnosis
      • Internal hemorrhoid
      • Incomplete study
  • 2022-12-19 ECG
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2022-12-19 CXR
    • Mild cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis.
    • Osteoporosis of the bones.
  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis with mild AR; mild MR; mild TR.
      • Mild aortic root calcification with multiple protruding atheromas (4-5 mm of thickness).
  • 2022-12-13 CT - abdomen
    • Clinical history: 77 y/o female patient with p3 (NSD)
      • prev abd op(-), low abd pain, leukorrhea and dysuria, low abd pain, leukorrhea and dysuria
      • 2022/12/12 sonar: EM 0.85cm RASD mass 7.3x7cm, solid?? uterine myoma or ROV tumor? ovarian malignancy cannot be excluded ROV cyst 5.3 x 5cm ascites > 500 c.c
    • With and without contrast enhancement CT of abdomen–whole:
      • Heteregneous cystic tumor, 7.6cm in right adnexa, r/o right ovarian malignancy.
      • Dilatation of the appendix with enhancement, r/o appendiceal malignancy.
      • Presence of massive ascites and soft tissue densities in the omentum, along peritoneum, r/o peritoneal carcinomatosis.
      • Large cystic tumor, 6.9cm in left lobe liver, r/o liver cyst.
      • Bilateral renal cysts, up to 1.6cm in right kidney.
      • Bilateral hydronephrosis.
      • No enlarged lymph node in the paraaortic region.
    • Impression:
      • Peritoneal carcinomatosis.
      • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
      • Right ovarian cystic tumor, r/o right ovarian malignancy.
      • Liver and renal cysts.
      • Bilateral hydronephrosis.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-12-12 Gynecologic Ultrasonography
    • Uterus Position: AVF
      • Size: 68 x 40 mm
    • Endometrium
      • Thickness: 8.5 mm
    • IMP
      • Ascites
      • R/O Rt mass or bowel ?? 73x33mm
      • R/O Rt cyst: 51x46mm

[consultation]

  • 2023-04-18 Hemato-Oncology
    • Q
      • This is a 78 y/o female with diagnosis of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12.
      • She received neoadjuvant intraperitoneal and systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP Q4W on 2023/02/14. However, general malaise, oral ulcer, poor appetite, skin rash , bilateral lower limbs edema and diarrhea were noted after first cycle of chemotherapy and was admitted during 2023/03/14 ~ 28.
      • Due to above reason, we would like to consult your expertise on evaluation and recommendation on chemotherapy for the patient, thank you!
    • A
      • This 78 year old woman is a case of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12, s/p systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP on 2023/02/14. Due to symptom after first cycle chemotherapy, we are consulted for furhter evaluation.
        • Perform HER2, programmed death ligand 1 (PD-L1), and microsatellite testing (if not done previously).
        • If intolerable to CapOx or FOLFOX, might consider docetaxel (30-35 mg/m2) plus 5-FU 2000-2600 mg/m2 and leucovorin 200 mg/m2 with or without cisplatin (20-30 mg/m2) Q2W.
        • Thanks for your consultation.
  • 2023-02-14 Gastroenterology
    • Q
      • for pre-chemotherapy HBV treatment
      • This 78 y/o female a case of gastric cancer with ovarian and peritoneal metastasis. She underwent HIPEC on 20230112. Further neo-adjuvant chemotherapy will arrange. However, we check hepatitis showed HBsAg and anti-HCV (-), but anti-HBc (reactive). We need your expertise for pre-chemotherapy HBV treatment. Thanks for your times.
    • A
      • P
        • Check HBV DNA
        • Arrange abdominal sonography
        • Vemlidy 25mg (GFR > 15 no adjustment; GFR < 15 contraindicated; HD: no adjustment, after HD)
        • GI OPD follow up
  • 2022-12-30 Anesthesiology
    • Q
      • For CVC insertion
      • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. She ever tried right neck for CVC insertion, but failure and iatrogenic pneumothorax was noted. Following CXR showed pneumothorax with pleural effusion of right side, thus pig-tail was inserted on 20221229. We need your expertise for CVC insertion. Thanks for your times. On femoral, thanks.
    • A
      • Finding
        • The sonography reported small, much thrombosis and overlapped with artery at right IJV and SCV.
        • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 ml.
        • We performed 3-lumen 7 fr CVC insertion to LEFT internal jugular vein under Seldinger technique
        • The CVC was fixed at 16cm
        • The pt tolerant the procedure well.
        • There was no sign of hematoma, pneumothorax, infection after the procedure.
      • The recommandation is as followed:
        • Please check chest roentgenography for localization.
        • Change IV set QD if TPN used or Q4D if general fliud.
        • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
        • We do not recommand routinely change the CVC unless there are some infectious signs.
      • Thanks for your consultaion.
  • 2022-12-27 Thoracic Surgery
    • Q
      • For CVC insertion
      • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. We need your expertise for CVC insertion. Thanks for your times.
    • A
      • Central venous catheterization has been tried but failed. Please consult ANES for the procedure. Thanks for your consultation.
  • 2022-12-26 Urology
    • Q
      • For on D-J catheterization.
      • This 77-year-old female with ovarian cancer was admitted for Debulking surgery at 20221227 . We need your evaluation of her condition for on D-J catheterization. Thanks for your help!
    • A
      • CT showed massive ascites and mild bilateral hydronephroiss
      • We will arrange bilateral DBJ insertion.
  • 2022-12-26 General and Digestive Surgery
    • Q
      • For combine surgery
      • This 77-years-old female with ovarian cancer and ascites was admitted Debulking surgery.
      • The abdomen CT scan revealed
        • Peritoneal carcinomatosis.
        • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
        • Right ovarian cystic tumor, r/o right ovarian malignancy.
      • Debulking surgery will arrange on 20221227 . We need your evaluation of her condition for combine surgery. Thanks for your help!
    • A
      • BW loss 7kg (49 -> 42) in past one month
      • suggest
        • we will performe combined surgery for her tomorrow
        • we will resected GI tract if necessary
        • PN support after operation
        • consult urologist for double J catheter implantation
        • We did not discuss with the family about HIPEC due to too weak to receive HIPEC
    • Supplementary reply 2022-12-26 17:41:10
      • PES: Advanced gastric cancer, type III, upper body, PW
      • impression: gastric cancer with peritoneal carcinomatosis and krukengerg tumor
      • suggest
        • debulking surgery is not indicated now
        • pending the report of pathology
        • nutrition support
        • may consider neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) with following total gastrectomy, cytoreductive surgery, BSO and HIPEC
      • we wound like to take over this case if the patient and her family agree

[MedRec]

  • 2023-04-06 SOAP General and Gastroenterological Surgery
    • S
      • fair appetite
      • tarry stool passage?
      • SOB?
    • O
      • smooth respiration
      • pink conjunctiva
      • bilateral lower limb pitting edema
    • P
      • admit for TS-1 and IP chemotherapy
  • 2023-03-07 SOAP General and Gastroenterological Surgery
    • S
      • poor appetite, bilateral lower limbs edema
      • pink conjunctiva
    • O
      • smooth respiration
      • but poor general condition
      • hold xeloda and dexamethasone
  • 2023-01-27 SOAP General and Gastroenterological Surgery
    • S
      • Gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, STAGE:IV post status laparoscopic examination and tumor excisional biopsy, laparoscopic tumor excision/debulking with right salpingo-oophorectomy, laparoscopic HIPEC and IP port implantation on 2023/01/12
      • Postprocedural pneumothorax status post thoracentesis on 2022/12/28
      • Malignant ascites
    • P
      • admission on 20230206 for bidirectional chemotherapy

[surgical operation]

  • 2023-01-12
    • Surgery
      • Diagnosis: suspected gastric cancer with ovarian metastasis (Krukenberg tumor?); pelvic bowel adhesion
      • laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis
    • Finding
      • previous gastric biopsy – malignancy (adenocarcinoma)
      • suspected gastric cancer with ovarian metastasis (Krukenberg tumor?)
      • right ovary and tube: 9x8cm, two parts–solid part 7x7cm, fragile, suspected metastastic cancer? ; cystic part 5x4cm with clear fluid
      • right tube -np (ROV + tube)
      • right pelvic tumor –2x2cm, solid suspected metastastic cancer?
  • 2023-01-12
    • Surgery
      • laparoscopic examination and tumor excisional biopsy
      • laparoscopic HIPEC
      • IP port implantation
    • Finding
      • serous ascites, about 2700ml
      • diffuse peritoneal carcinomatosis, total PCI: 23/39
      • RUQ 2
      • epigastrium 2
      • LUQ 2
      • right flank 1
      • central 1
      • left flank 1
      • RLQ 3
      • pelvis 3
      • LLQ 2
      • small bowel PCI: 2+2+1+1/12
      • HIPEC: oxalipatin 400mg + paclitaxel 120mg in D5S 3000ml, 90min, 42 degree

[chemotherapy]

  • 2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)

  • 2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)

  • 2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min

Xeloda (capecitabine 500mg) KXEL)01

  • 2023-02-16 ~ 2023-03-14 2# BID

[assessment]

  • Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.

  • Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.

  • The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.

  • Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.

701445069

230428

[exam findings]

  • 2023-04-26 CXR
    • extensive heterogeneous consolidation in both hypoinflated lungs due to severe pulmonary fibrosis in progression as compared with the previous image
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • enlarged cardiac silhoutte due to dilated prominent pericardial fat/prominent cardiophrenic angle mediastinal fat pad/ supine position
  • 2023-04-21 CT - chest
    • Indication: Malignant neoplasm of unspecified part of left bronchus or lung
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • There is enlarged lymph nodes in the mediastinum. In comparison with CT dated on 2023-02-17, these lymph nodes increased in size and numbers
        • There is interstitial change at both lungs with honey combing mostly at bilateral peripheral and lower lungs. In comparison with CT dated on 2023-02-17, the extension and severity progressed slightly.
        • Minimal pericardial effusion is found.
      • Visible abdomen:
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
    • Imp:
      • Interstitial change of both lungs. In progression.
      • Enlarged lymph nodes in the mediastinum. In enlargement.
      • Minimal pericardial effusion.
  • 2023-03-22, -03-15, -02-15, -01-26, -01-20, -01-16, -01-11, -01-06, -01-03, 2022-12-29, -12-26, -12-22, -12-19, -12-08, … CXR
    • There are linear and nodular opacities projecting at bilateral middle and lower lung that are c/w subpleural boneycombing feature after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Spondylosis of the T-spine
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (47 - 11) / 47 = 76.60%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild TR
  • 2023-07-17 CT - chest
    • Diagnosis
      • Malignant neoplasm of unspecified part of left bronchus or lung
      • Hypertensive heart disease without heart failure
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at left upper lobe with bony erosion measuring 4.57x1.45cm in largest dimension. In comparison with CT dated on 2023-01-17, the lesion is stationary or slightly regressed.
        • Diffuse interstitial change at both lungs with honey combing at bilatearl lower lungs are found. IPF is considered.
        • Ground glass patches at both lungs is found. In regression.
        • Calcified coronary arteries is found.
        • Hypertrophic left ventricle is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • Imp:
      • left upper lobe lung cancer with bony erosion, in regression.
      • Diffuse intertitial change at both lungs with lower lobes predominance. IPF is suspected.
      • Hypertrophic left heart with Calcified coronary arteries is found.
  • 2023-01-17 CT - chest
    • Indication: Lung cancer with dyspnea
    • Comparison was made with previous CT dated on 2022/12/16
      • Chest
        • interval significant decrease in size of a large tumor at left upper anterior chest wall and heterogeneous consolidation at LUL as compared with CT on 2022/12/16.
        • there is subpleural and basal predominant pulmonary fibrosis charaterized by reticulation, traction bronchiectasis, traction bronchioectasis, archiectural distortion, and subpleural honeycombing.
        • extensive centrilobular emphysema and subpleural paraseptal emphysema at both upper lobes too.
        • Mediastinum and hila: interval regression of extensive lymphadenopathy the visceral space and both hila,as compared with CT on 2022/12/16
        • mild calcified plaques of the LAD, and LCX, and right coronary arteries.
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: mild dilated right main artery.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace Lt-sided effusion
      • Visible abdominal-pelvic contents:
        • normal appearance of gall bladder.
        • several bilateral renal cysts measuring up to 1.5cm (longest axial diameter)
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16.
      • combined emphysema and IPF.
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (43 - 19) / 43 = 55.81%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Mild MR, trivial TR
      • Preserved RV systolic function
  • 2022-12-22 MRI - brain
    • Clinical information: Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA, R/O brain metastasis
    • Findings:
      • Known a case of lung cancer. No evidence of brain metastasis.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • An outpouch (8.5 mm) projecting anteriorly from ACom artery, indicating an aneurysm. Suggest endovascular treatment.
  • 2022-12-16 CT - chest
    • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) C3D15 Visit >
      • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Mass like lesion occupying left anterior chest about 7.9cm in largest dimension is found. Stable.
        • S/p port-A placement with its tip at Superior vena cava.
        • Centrilobular Emphysematous change over both lungs and honey combing at peripheral lungs is found. IPF like change is considered. In comparison with CT dated on 2022-10-07, the lesion progressed rapidly.
        • Tortous aorta with calcification is noted.
        • Enlarged, enhanced lymph nodes are found at both sides of the mediastinum, in enlargement.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp: Left anterior chest wall lung cancer s/p treatment with immune related pulmonary fibrosis. The primary tumor is stationary in size but the mediastinal lymph nodes enlarged. Pseudoprogression? Suggest close observation.
  • 2022-12-08 CXR
    • Patchy opacity projecting at left upper lateral lung was noted that is c/w lung cancer after correlate with CT.
    • There are several nodular opacities projecting at both lung. Please correlate with CT to R/O lung to lung metastases?
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-11-17, -10-27 CXR
    • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-10-12 CXR
    • Patch densities at bil. lungs.
    • Atherosclerosis of the aorta.
  • 2022-10-07 CT - chest
    • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) Screening ICF Process >
      • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family via both on-site and remote on 2022.09.15, and on site disscussion on 2022.09.28.
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass attaching left anterior chest about 6.28cm in largest dimension is found. In comparison with CT dated on 2022-08-04, the lesion enlarged.
        • Centrilobular Emphysematous change over both lungs is found.
        • Cystic fibrotic change and cystic Bronchiectatic change at both peripheral lungs is found. Stationary.
        • Patent airway is found.
        • Enlarged lymph nodes are found at both sides of the mediastinum. Stationary.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy, The primary tumor enlarged.
      • COPD.
  • 2022-10-06 MRI - brain
    • ACom aneurysm (8.5 mm).
    • No interval change as compared with MRI on 20220822.
    • Please close follow up and consult neurosurgeon.
    • No evidence of brain metastases.
  • 2022-10-04 Tc-99m MDP whole body bone scan
    • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion.
    • Increased activity lower T- to upper L-spines and lower L-spines. Either bone metastases or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in the sternum and bilateral rib cages. Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-04 Pulmonary Function Test, Spirometer
    • preexam spo2:98%; postexam spo2:94%
    • mild obstructive ventilatory impairment with partial reversibility, FEV1/FVC 65%, FVC 81->92%, FEV1 68->77%
    • normal slow vital capacity, SVC 89%
    • airway trapping, RV/TLC 131%
    • normal diffusing capacity, DLCO/VA 73% (low DLCO 58% favor due to low VA)
    • suggest to use bronchodilator such as spiriva for mild obstructive ventilatory impairment
  • 2022-08-31 ROS1 FISH
    • ROS1 fluorescent-in-situ hybridization report
    • Rearrangement of ROS1 gene is NOT detected.
    • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-08-31 ALK IHC
    • Result: Negative
    • The immunostaining of the section slide labeled S2022-13261, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-08-23 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower T- to upper L-spines and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-08-22 MRI - brain
    • History and Indication
      • hemoptysis and severe chest pain
      • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
      • Active smoking 1/2+ PPD for 30+ years
      • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
      • 20220803 EKG: sinus rhythm, 1st AV block
      • 20220803 Current medications: aspirin 1# QD, inderal 1# BID, atozet 1# QD, gaster 1# BID, erispan 1# BID, stilnox 1# prnHS, uricin 1# QD
      • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
    • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor space-occupying lesion.
      • No remarkable finding of skull base and bony structures.
      • No remarkable finding of nasopharynx visible in these images.
      • An outpouch (8 mm) projecting anterolaterally from ACom artery, indicaitng an aneurysm.
    • IMP: ACom aneurysm (8 mm). Mild general brain atrophy.
  • 2022-08-19 EGFR gene mutation
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen S22-13261
  • 2022-08-19 PD-L1 (22C3)
    • PD-L1 Immunostaining Result
      • Tumor Proportion Score (TPS) assessment: 95%
      • Combined Positive Score (CPS) assessment: 95
  • 2022-08-12 Patho - bronchus biopsy
    • Labeled as “left chest wall tumor”, needle biopsy — non-small cell carcinoma.
    • IHC stains:
      • TTF-1 (-), Napsin-A (-), p40 (focal +), calretinin (-), CK7 (+), CK20 (-).
      • GATA-3 (-), CK5/6 (+), p63 (+). The pattern is in favor of squamous cell carcinoma.
    • Section shows fibrotic soft tissue with infiltration of irregular nests of non-small cell carcinoma.
  • 2022-08-11 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the inferolateral wall, basal lateral wall and posterior wall.
  • 2022-08-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 31) / 79 = 60.76%
      • M-mode (Teichholz) = 60
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, concentric LVH; LV diastolic dysfunction, Gr 1
    • Trivial MR, trivial AR and trivial TR
    • Preserved RV systolic function
  • 2022-08-04 CT - chest
    • Findings
      • Chest:
        • Severe centrilobular Emphysematous change over both lungs is found.
        • Pleural based fibrotic change at both lungs more on peripheral lung is found.
        • Soft tissue mass encasing left atnerior chest wall with bony invasion is found up to 4.5cm. suggest tissue proof.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • IMp:
      • Severe COPD.
      • Soft tissue mass encasing left atnerior chest wall with bony invasion is found. suggest tissue proof.
  • 2022-08-03 CXR
    • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-08-03 ECG
    • Sinus rhythm with 1st degree A-V block
    • Nonspecific ST abnormality

[MedRec]

  • 2023-04-26 SOAP MER
    • S
      • SOB and desaturation during OPD
      • He developed decreased O2 Sat 5 days (90-95% initially), S/S exacerbated recent 2 days (<90%, about 84%)
        • no fever
        • no chest pain
      • A case of lung ca received clinical trial Tx, got PCP, CMV infection Hx
      • CXR showed pneumonitis
    • A/P
      • Respiratory failure, hypoxia, Critical, CRP15, bil PN
      • Hx: left lung CA, HTN, COPD; Patent CAD many years ago, PCP, CMV infection
      • CRP 15.4, WBC 7k, Medason, Tapimycin; OA Hema
      • 20230421 lung CT: Interstitial change of both lungs. In progression.
  • 2023-04-26 SOAP Dermatology
    • S: itchy and sweating sensation over trunk for weeks.
    • O
      • Diffuse annular lesions with spreading tendernecy and mild pruritus over trunk and gerion for weeks.
      • Past history: denied major systemic disease
      • Impression: tinea cruris et intertrigo eczema.
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI 7D
      • Zalain (sertaconazole nitrate) BID TOPI 7D
  • 2023-04-19 SOAP Hemato-Oncology
    • P
      • Due to purpura over arms and legs, the subject uses Hirudoid Gel, which is over the counter medicine, from 2023-04-19.
      • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-04-19 to 2023-04-21.
  • 2023-04-12 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for 4 more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-05-10
  • 2023-03-29 SOAP Hemato-Oncology
    • P: For creatinine increased, hydration is given to the subject from 2023-03-29 to 2023-03-31.
  • 2023-03-29 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-04-12
  • 2023-03-22 SOAP Hemato-Oncology
    • P: Due to improvement of appetite, the dose of megestrol was adjusted from 160 mg PO QD to 80 mg PO QD since 2023-03-16.
  • 2023-03-16 SOAP Hemato-Oncology
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 2 from 2023-01-26 to now, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
      • Diarrhea Gr 1 from 2022-12-05 to 2022-12-18, not related to IP.
      • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
      • Lung infection Gr 2 from 2023-01-21 to 2023-01-26, not related to IP.
      • Cytomegalovirus infection reactivation Gr 1 from 2023-01-16 to 2023-01-30, Gr 2 from 2023-01-31 to 2023-03-14, not related to IP.
      • Alanine aminotransferase increased Gr 1 from 2023-02-22 to 2023-03-14, not related to IP.
      • Aspartate aminotransferase increased Gr 1 from 2023-02-08 to 2023-02-21, not related to IP.
      • Anemia Gr 2 from 2023-01-09 to 2023-01-12, not related to IP.
      • Creatinine increased Gr 1 from 2023-03-01 to 2023-03-07, not related to IP.
      • Blood bilirubin increased Gr 1 from 2023-03-08 to now, not related to IP.
  • 2023-03-15 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-03-29
  • 2023-03-15 SOAP Hemato-Oncology
    • O
      • 2023/03/13 CMV viral load assay = Target not deteceted IU/mL;
      • 2023/02/20 CMV viral load assay = <35 IU/mL;
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: For prevention of creatinine increased, hydration is given to the subject from 2023-03-15 to 2023-03-16.
  • 2023-03-01 SOAP Hemato-Oncology
    • P: For Gr 1 creatinine increased, hydration is given to the subject from 2023-03-01 to 2023-03-03.
  • 2023-02-22 SOAP Infectious Disease
    • A: reduce Valcyte dose to 2# qd for two weeks, has received 3-week full dose Valcyte till 2023-02-22
    • P: FU on 2023-03-08
  • 2023-02-22 SOAP Hemato-Oncology
    • O
      • 2023/02/20 CMV viral load assay = <35 IU/mL;
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
  • 2023-02-15 SOAP Hemato-Oncology
    • P: For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-02-15 to 2023-02-17.
  • 2023-02-08 SOAP Hemato-Oncology
    • O
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, follow up CMV viral load after 2 weeks of using Valcyte and adjust Prednisolone from 4 tab QD to 2 tab QD.
  • 2023-02-08 SOAP Infectious Disease
    • S: CMV related hepatitis follow up, easy fatigue, exertional dyspnea, intake still acceptable, loss of weight 1kg.
    • O
      • BT no fever, BW 65.2kg
      • 20230208 AST/ALT 80/335,
      • 20230206 CMV viral load 181
    • A
      • refill Valcyte for the 2nd and 3rd week therapy
      • reduction of steroid use indicated
    • P: FU on 2023-02-22
  • 2023-02-01 SOAP Infectious Disease
    • S
      • 2023/02/01 Referred from Onco OPD for CMV related hepatitis
      • no cough, exertional dyspnea and easy fatigue still noted,
      • PJP and interstitial lung discharged from Onco on 2023-01-20, with prednisolone and Baktar use
      • Underlying lung cancer, cT4N3M1b stage IVA SCC, cachexia.
    • O
      • BT no fever
      • 20230131 WBC 23290, AST/ALT 131/252
      • 20230127 CMV viral load assay = 62 IU/mL;
      • 20230117 CT chest: LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16. combined emphysema and IPF.
      • 20221224 CMV viral load not deteceted;
    • A
      • refill Valcyte for one week first, under CMV-related hepatitis impression.
    • P
      • FU on 20230208
  • 2023-01-31 SOAP Hemato-Oncology
    • O
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, prescribe Valcyte and refer to Infection expertise for futher evaluation and management.
    • Prescription
      • Valcyte (valganciclovir 450mg) 2# BID 1D
  • 2023-01-26 SOAP Hemato-Oncology
    • P:
      • Due to impaired renal function which might be related dehydration, IV fluid support will be given.
      • In addition, potassium-binding agent will be used for hyperkalemia.
    • Presciption
      • Kalimate (calcium polystyrene sulfonate 5mg) 1# QD 5D
  • 2022-12-15 SOAP Hemato-Oncology
    • P: Because new main ICF (Version 2.0, 12-Oct-2022) and Optional Future Research ICF (Version 1.0, 12-Oct-2022) are proven, I give the new version ICF to the subject and let the subject have adequate time to read it, subsequently ask question and discuss with us. Then the subject sign the version ICF on 2022-12-15. A copy of the signed main ICF and Optional Future Research ICF were provided to the subject.
      • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2022-12-15 to 2022-12-17.
      • The subject discontinued Cyproheptadine from 2022-12-15, and switched to Megestrol Acetate 160 mg PO QD for anorexia from 2022-12-15.
      • Due to relatively lower BP and occasionally dizziness, the subject hold Bisoprolol Fumarate from 2022-12-08.
      • The subject discontinued Lorazepam from 2022-12-08, and switched to Quetiapine from 2022-12-08.
      • Due to Morphine induced dry mouth, the subject discontinued Morphine and switched to Tramacet from 2022-12-08.
      • On 2022-12-16, the CT revealed the possibility of lung infection or pneumonitis. Therefore, oral empirical antibiotics with cephalexin 500 mg Q6H is given since 2022-12-16. If not working, admission for lung infection would be done.
    • Prescription
      • cephalexin 500mg 1# Q6H 7D
  • 2022-12-07 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
        • Diarrhea Gr 1 from 2022-12-05 to now, not related to IP.
        • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
    • P
      • Due to sweating a lot, hydration is given to the subject from 2022-12-07 to 2022-12-09.
      • Cyproheptadine 4 mg PO TID for anorexia from 2022-12-07.
      • The subject discontinued Orolisin from 2022-11-30.
  • 2022-11-30 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
        • Diarrhea Gr 1 from 2022-11-28 to 2022-11-29, not related to IP.
    • P
      • Due to suspect the sweating coming from taking Tramacet (tramadol/acetaminophen), discontinued Tramacet from 2022-11-17.
      • Because the subject mentions the eczema over bilateral upper limbs which is actually existed before being enrolled onto this trial, Levocetirizine, Fluocinonide and Urea are prescribed by dermatologist on 2022-11-30.
      • Due to sweating a lot, hydration is given to him on 2022-11-30.
  • 2022-11-30 SOAP Dermatology
    • S: itchy over exposesite of upper limbs
    • O: Widespread multiple reddish to brownish maucles, papules and confluent plaques with excoriations and scales over the upper limbs for months. No fever
      • Past history: denied major systemic disease
      • Impression: eczema, less likely drug-related. r/o pityriasis disorder.
    • P:
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# QN
      • Topsum Cream (fluocinonide 0.05%) BID EXT
      • Sinpharderm Cream (urea) BID TOPI
  • 2022-11-24 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to now, not related to IP.
    • P
      • Sodium Chloride for hyperkalemia (K: 5.9 mmol/L)
      • Triamcinolone 1 qs TOPI PRNBID for prevention of mucositis.
  • 2022-11-09 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-03 to 2022-11-08, not related to IP.
    • P: Due to sweating after taking Tramacet (tramadol/acetaminophen), hydration is given to him on 2022-11-09.
  • 2022-11-03 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to now, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-03 to now, not related to IP.
    • P
      • Triamcinolone for mucositis oral from 2022-11-03.
      • Sodium Chloride for hyperkalemia (K: 5.7 mmol/L)
  • 2022-10-27 SOAP Hemato-Oncology
    • S
      • BGB-A317-A1217-302 (iIRB No: 10-FS-043) C1D8 Visit
        • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
        • C1D1 on 2022-10-20
    • O
      • PE (Body system: vision, general, HEENT, cardiovascular, chest and respiratory, abdomen, extremities/musculoskeletal, neurological) –> Yes & maculopapular rash and plaques
      • Examinations and Tests
        • Sample collection:
          • Lab tests:
            • Blood collection at 08:57 AM on 2022-10-27
            • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo; ADA of Tislelizumab or Pembrolizumab & A1217 or Placebo (pre-dose): Nil
            • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo (post dose within 30mins): Nil
      • AE: Fever Gr 1 on 2022-10-20, related to IP.
    • P
      • Monitor adverse event
  • 2022-10-18 SOAP Hemato-Oncology
    • P
      • Acetylcysteine 600 mg PRBBID PO for productive cough.
      • Piroxicam 1 QS PRNBID TOPI for tumor pain.
  • 2022-10-12 SOAP Hemato-Oncology
    • P
      • Refil the medicine
      • The subject has still Aspirin, Bisoprolol, Atozet, Candesartan, Famotidine, Sennoside, Morphine, MgO, Acetylcysteine, Fluocinonide, Orolisin, Exelderm Cream, Urea at home, no priscription on 2022-10-12.
  • 2022-10-04 SOAP Hemato-Oncology
    • P
      • Refil the medicine
      • Actein for prevention of contrast-induced nephropathy.
      • Preliminarily discuss the content of trial on 2022-09-15 and 2022-09-26.
  • 2022-09-20 SOAP Hemato-Oncology
    • S
      • << BGB-A317-A1217-302 (iIRB No: 10-FS-043) Pre-screening ICF Process >>
        • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family on 2022.09.15, using the virtual discussion via web.
        • Before the Pre-screening informed consent form (V1.1_TC_20May2021) is signed, the Pre-screening ICF was read by patient and family with adequate time.
        • They had enough time to ask questions and I answered their questions thoroughly as well.
        • The subject agreed to provide the tumor slides to central lab for determination of PD-L1 expression, and had signed Pre-screening informed consent form on 2022.09.20.
        • A copy of the signed Pre-screening informed consent form was provided to the subject.
    • O
      • Study Title: BGB-A317-A1217-302
      • A Phase 3, Randomized, Double-Blind Study of BGB A1217, an Anti TIGIT Antibody, in Combination With Tislelizumab Compared to Pembrolizumab in Patients With Previously Untreated, PD L1 Selected, and Locally Advanced, Unresectable, or Metastatic Non Small Cell Lung Cancer
      • Pre-screening No.: SCR-886019-001
      • Initial: SJC
      • Date of birth: 1940.11.23
      • Gender: Male
      • ALK IHC: Negative
      • EGFR: Negative
    • A
      • Anticipate to arrange the freshly cut unstained FFPE slides on 2022-09-20.
  • 2022-09-15 SOAP Hemato-Oncology
    • O
      • 2022/08/31 Anti-HBc = Reactive;
      • 2022/08/31 Anti-HBc-Value = 7.15 S/CO;
      • 2022/08/31 ROS1 FISH: Negative
      • 2022/08/31 ALK IHC: Negative
      • 2022/08/19 EGFR: Negative
  • 2022-08-30 SOAP Hemato-Oncology
    • A
      • ALK, ROS1 and lab
      • T3N0M1a stage M1a SCC
  • 2022-08-17 SOAP Cardiology
    • Prescription
      • Bokey (aspirin 100mg) 1# QD 14 days
      • Concor (bisoprolol 5mg) 0.5# QD 14 days
      • Atozet (ezetimibe 10mg + atorvastatin 20mg) 1# QD 14 days
      • Blopress (candesartan 8mg) 1# QD 14 days
      • Ulstop (famotidine 20mg) 1# QD 14 days
  • 2022-08-03 SOAP Chest Medicine
    • S
      • hemoptysis
      • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
      • Active smoking 1/2+ PPD for 30+ years
      • Denied past history of DM
      • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
      • 20220803 EKG: sinus rhythm, 1st AV block
      • 20220803 Current medications:
        • aspirin 1# QD,
        • inderal 1# BID,
        • atozet 1# QD,
        • gaster 1# BID,
        • erispan 1# BID,
        • stilnox 1# prnHS,
        • uricin 1# QD
      • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
      • Arrange echocardiography and Tl-201 myocardial perfusion scan for further evaluation

[chemoimmunotherapy]

  • 2023-04-07 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2023-03-16 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2023-02-23 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-12-01 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-11-10 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-10-20 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)

==========

2022-12-29

[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing]

  • Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.

    • In-hospital Baktar spec: sulfamethoxazole 400mg + trimethoprim 80mg in 5mL/amp. The patient’s body weight is 70kg.
    • 70kg * 15 = 1050mg ~ 13.125 amp ~ 4amp TID or 3amp QID
    • 70kg * 20 = 1400mg ~ 17.5 amp ~ 6amp TID or 4amp QID
  • As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.

  • Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.

700691239

230427

{not completed}

[exam findings] (not completed)

  • 2023-04-25 MRI - pelvis
    • Indication: posterior iliac crest tender mass, r/o abscess formation
    • With and without-contrast multiplannar and multisequences MRI of pelvis revealed:
      • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
      • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
      • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
    • Impression
      • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
      • c/w bone metastasis in spine, right sacral ala, and left acetabulum
  • 2023-04-13 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • 2023-04-06 SONO - abdomen
    • Right renal cyst (0.90x1.38cm).
  • 2023-03-23 MTBC PCR
    • S2023-04099 — Positive
  • 2023-03-07 Patho - bone exostosis
    • Soft tissue, labeled as “bone, right sacral”, CT-guide biopsy — Necrosis
      • NOTE: Correlation of micro-organism culture, image study and clinical findings is recommended.
    • Microscopically, it shows necrotic debris, mixed inflammatory infiltrate of lymphocytes and leukocytes and focal stromal fibrosis.
    • Immunohistochemical stain reveals CK(-) and GATA3(-) for tumor.
    • Acid-fast stain — Positive for mycobacterial bacilli, PAS stain — Negative; Suggest of mycobacterial infection
  • 2023-03-06 CXR
    • Old fracture of right clavicle S/P compression plate and screws fixation shows good alignment and good union.
    • There is soft tissue density in paraspinal area in T11-T12 level. Please correlate with CT.
    • Osteolytic lesion in T12 vertebral body is highly suspected.
  • 2023-03-01 PET scan
    • Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases. .
    • Increased FDG uptake in soft tissue in the RLQ and LUQ of abdomen, the nature is to be determined (another primary malignancy or others ?), suggesting biopsy for further investigation.
    • Right breast cancer s/p treatment, highly suspected tumor (breast or others ?) with multiple bone metastases, by this F-18 FDG PET scan.
  • 2023-02-16 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/02/16, the lesions in the lower T-spines, manubrium of the sternum, right aspect of sacrum, adjacent right iliac bone and inferior aspect of left acetabulum are new.
    • Multiple bone metastases should be watched out.
  • 2023-02-10 CT - abdomen
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • There are osteoblastic change from T11 to L1.
        • In addition, There is osteolytic lesion in T12 vertebral body and soft tissue tumor extension from T12 vertebral body into anterior and left lateral aspect of the vertebral body and left psoas muscle.
        • Metastases are highly suspected. Please correlate with tumor marker and PET scan.
      • There is an ill-defined osteoblastic change and osteolytic lesion in right 1st sacrum that also may be bony metastasis.
      • Two low density lesion in the upper pole of both kidney are noted. Please correlate with sonography to R/O cyst?
      • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • IMP:
      • Bony metastases are highly suspected.
      • Please correlate with tumor marker and PET scan.
  • 2023-02-06 SONO - nephrology
    • Bilateral renal cysts
  • 2022-12-26 SONO - abdomen
    • Right renal cyst and stone.

[consultation]

  • 2023-04-26 Anesthesiology
    • Q
      • This 53-year-old female patient has past history of
        • Left breast tumor s/p left tumor excision in 2003
        • Right clavicle fracture s/p ORIF
        • Right breast tumor s/p tumor excision after needle localization on 2022/01/28
      • Right breast ductal carcinoma in situ status post right axillary sentinel lymph node biopsy on 2022-03-11. She denied any TOCC histories in recent 3 months.
      • This time she was admitted due to right iliac crest biopsy site severe pain with tenderness for 2 days. The pain was accompanied with fever up to 39.5 degC and chillness.
      • Under the impression of right iliac crest cellulitis, she was admitted for antibiotics treatment.
      • 2023/03/01 bone scan: Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases.
      • However, on 2023/03/02 Bone marrow biopsy showed no metastatic carcinoma
      • 2023/03/07 CT-guided biopsy of right sacrum showed positive AFS, and subsequently at 2023/03/23 tissue report showed TB positive
      • Lab data (20230424): CRP 12.68, WBC 15010; blood culture result pending
      • Currently the patient has been taking AKuriT-4 for 5 weeks.
      • MRI pelvis done on 20230425 showed c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
      • ID man suggested needle aspiration by radiologist; and Radiologists warned us about the risk of cutaneous fistula formation and skin TB after drainage procedure.
      • This morning, the patient started to notice right leg numbness radiating from hip downward from the side of thigh all the way down to right sole, but resolved after 2 hours
      • PE showed pain on right hip flexion, and restricted AROM on right hip extension.
      • Therefore, we also consulted neurosurgeon and replied no apparent invasion of spine.
      • GS was also consulted, and due to the lesions were deeply located, therefore, surgical debridement was not feasible
      • ORTHO will arrange debridement for her right sacral abscess on 20230427.
      • This time we would really need your expertise in providing preoperative anesthetic evaluation for this patient.
      • Thanks a lot in advance!
    • A
      • I’ve visited the patient and reviewed her data
      • CC: right iliac crest severe pain with tenderness, fever and chillness
      • DX: c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
      • OP: right sacral abscess debridement on 20230427
      • Anes plan:
        • ASA III
        • We will arrange ETGA for this patient
        • The patient has been informed on the anesthesia- and surgery-associated risks
  • 2023-04-25 Neurosurgery
    • Q
      • This time we would really need your expertise in evaluating the feasibility of incisional drainage with biopsy, and the possible cause of right sciatica.
    • A
      • A case of 53 y/o female, Hx have been reviewed; Extrapulmonary TB(+) under Tx.
      • NS is consulted for right LBP and wraist mass with tenderness; Fever(+);
      • O
        • Current status: Cons: clear
        • Walk ok; MP: bil 5-; sensation: symmetric; gait: fair; sphincter: continence
        • A pelvis MRI:
          • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
          • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
          • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
      • A
        • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
        • c/w bone metastasis in spine, right sacral ala, and left acetabulum; breast cancer
      • P
        • May arrange CT guide or echo guide pigtail drainage and biopsy; pain control; Tx TB as usual;
  • 2023-04-22 Infectious Disease
    • A
      • 81-year-old breasst cancer female patient has right sacroiliac crest TB and has received 5 more week anti-TB treatment till now.
      • O
        • Painful growing mass is noted over right posterior lower back, where previous biopsy site.
        • Lab data revealed no drop of ESR and CRP levels.
      • A
        • Either hematoma or abscess formation is the first consideration.
        • No need for change the anti-TB regimen, but MRI or CT study necessary for the mass lesion nature.
      • Suggestion
        • Continue the present AkuriT-4 medication to complete the first 60-day medication.
        • Continue Tramacet and add Celebrex for pain relief.
        • Arrange MRI of T-L-S spine for evaluation of spine and iliac mass lesion.
  • 2023-03-10 Infectious Disease
    • A
      • 52-year-old breast cancer with suspect multiple bony metastases female patient, received right sacrum bone biopsy on 2023-03-07.
      • Patholgoy report revealed positive AFB smear and no cancer cell, that bone TB is the first consideration.
      • Review the PET report, there are multiple bone lesions, including sternum, T-spine, right sacrum and left acetabulum.
      • TB bone rarely presents so many sites.
      • TB bone culture was not done, that bone tissue TB-PCR study is necessary.
      • Please contact the TB practioner.
      • TB disease notification is necessary first, that anti-TB therapy can be started, even without PCR report.

[assessment]

  • AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.

  • It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.

701048984

230427

[diagnosis] - 2023-03-29 admission note

  • gastric cancer with liver invasion, cT4bN1M0, stage IV s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection
  • constipation

[past history] - 2023-03-06 admission note

  • The patient had no systemic diseases
  • history of operation:
    • gastric cancer with liver metastasis, cTT4bN2M1, stage IVB, s/p liver S3 partial resection, cholecystectomy, choledochoduodenal bypass and gastrojejunal bypass on 2023/01/09
  • Regular medications or herb:
    • Tramacet 1tab PO HS
    • Sketa 1tab PO TID
    • Pariet 1tab PO QDAC
    • Mosapride 1tab PO TID         

[allergy]

  • NKDA         

[family history]

  • His father has hypertension.
  • Denied of any families have cancer history.

[exam findings]

  • 2023-04-18 Patho - stomach biopsy
    • Stomach, proximal to the anastomosis site, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows fragments of gastric tissue with chronic inflammation, intestinal metaplasia and focal invasive cribriform glands.
    • The immunohistochemical stain of CK is positive.
  • 2023-04-18 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Gastric ulcer, LC site, proximal to the anastomosis, s/p biopsy
      • Remnant gastritis
      • Post subtotal gastrectomy with Billroth II anastomosis
    • Suggestion
      • Keep PPI therapy
      • Pursue pathology report
  • 2023-04-02, -02-06, -02-04 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-02-04 CXR
    • Atherosclerosis of the aorta.
    • Presence of ileus.
  • 2023-01-09 Patho - liver partial resection
    • Gallbladder, cholecystectomy — Chronic cholecystitis and cholelithiasis
    • The sections show a picture of chronic cholecystitis and cholelithiasis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
  • 2023-01-09 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S3, partial S3 resection — Adenocarcinoma, moderately differentiated, compatible with gastric origin
    • MACROSCOPIC EXAMINATION
      • Procedures: Partial S3 resection
      • Specimen Size: 4.5 x 3.2 x 2.5 cm
      • Tumor Focality: Solitary
      • Tumor Site: S3
      • Tumor Size: 0.8 x 0.6 x 0.4 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A2 = tumor, A3 = non-neoplastic liver
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Adenocarcinoma, compatible with gastric origin
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Moderate (40%)
      • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.2 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation, no interphase hepatitis, no lobular inflammation, and regenerative hepatocytes
      • Fatty Change: Present (3%)
  • 2023-01-05 CT - abdomen gastric filling with water
    • History and indication: gastric cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large ulcerative lesion at gastric antrum with regional LAP.
      • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
      • Gallbladder stone (6mm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • No abnormal density at bilateral basal lungs.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-01-04 Flow Volume Chart
    • normal screening
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 34) / 94 = 63.83%
      • M-mode (Teichholz) = 64
    • Adequate LV systolic function with normal resting wall motion
    • Trivlal MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
  • 2022-12-28 Patho - stomach biopsy
    • Stomach, antrum LC, biopsy — Adenocarcinoma.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+).
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic cells.
  • 2022-12-27 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Superficial gastritis, s/p CLO test
      • Suspected gastric cancer, antrum, LC site, s/p biopsy
    • Suggestion
      • Pursue pathology report
  • 2021-02-23 Auditory Brainstem Response, ABR
    • Absence of ABR wave I was noticed in L’t ear.
    • Prolonged ABR wave I latency in R’t ear.
    • ILD-V 0.08
    • no evidence of retrocochlear lesion
  • 2021-02-16 ENT Hearing Test
    • PTA:
      • Reliability FAIR
      • Average R’t 30 dB HL; L’t 44 dB HL
      • R’t normal to profound SNHL.
      • L’t normal to severe SNHL.
    • Tymp: Bil type A.
    • ART:
      • R’t ipsi 4k Hz and contra absent.
      • L’t absent.

[consultation]

  • 2023-04-17 Anesthesiology
    • Q
      • for anesthesia assessment
      • Arrange painless of EGD on 4/18 8AM
      • This 80-year-old male, who has a histiry of gastric cancer with liver invasion, cT4bN1M1 s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09 s/p palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin. He suffered from initial presentation of RUQ of abd pain in Jan 2023, s/p sent to ER of ShuangHe Hospital and weight loss (+) (5kg in 12 months). Surgical pathology with liver, S3, partial S3 resection (20230109) proved Adenocarcinoma, MD. c/w gastric origin. Gallbladder, cholecystectomy: Chronic cholecystitis and cholelithiasis. Ascites (20230109) showed negative. Stomach, antrum LC, biopsy (20221227) proved adenocarcinoma.IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+). He received gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09, and received palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin Q2W x 12 , #1 on 20230216, #2 on 20230306, #3 on 20230330 - Acording to the patient describe, he suferred from vomiting dark red once and tarry stool noted on 2023/04/15, so he was brought to ChangGung Hospital for help first, then due to personal reason, so he went to our ER for help. At ER, the vital signs: BT 36.3 degC; HR: 99bpm; RR: 18bpm; SpO2 98% under room air, conscious: E4V5M6. The lab of CBC/DC showed anemia (Hb: 8.8g/dL), so gave blood tranfusion with LPRBC, hydration, Transamine, and PPI with Pantoloctreatment. After treatment, the Hb level go up to 10.1g/dL. Under the impression of Gastrointestinal hemorrhage, so he is admitted for future evaluation.
    • A
      • 80 y/o man has
        • Hx: gastric cancer stage VI
        • gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09
      • Dx: GI Bleeing
      • Op: PES
      • Condition: Cons. clear, previous walking ok but now weakness and tired unable to sit on wheelchair, no dyspnea, chest tightness or leg edema
      • Lab: Hb10
      • ASA3
      • Plan:
        • High risk of aspiration, sepsis, shock
        • Anes. plan and risk was told to him at bedside
        • Resucitation, ETT will be procedured if emergence condition.
        • We will arrange IVGA, GI man will injection local anesthsia at GI tract.
        • Correct underly dx such as anemia, hypovulemia as your expertise.
        • Follow onetouch q6h or even q4h when nil per os if DM or high risk of hypoglycemia

[surgical operation]

  • 2023-01-09
    • Surgery
      • Laparoscopy
      • Liver S3 partial resection
      • Cholecystectomy
      • Choledochoduodenal bypass
      • Gastrojejunal bypass
    • Finding
      • A whitish hard tumor was protruding from the anterior wall of gastric antrum near lesser curvature.
      • A whitish tumomr was noted at the posterior wall of S3 segment, r/o direct invasion from the gastric tumor.
      • Hard tumors were noted at the pancreatic head and retroperitoneum.
      • After discussion with his family, tumors could not excised entirely. His son agreed with performing bypass surgery only.
      • No gallbladder stone was found.
      • At least cT4bN1

[chemotherapy]

  • 2023-04-27 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 100mL 2hr + fluorouracil 2000mg/m2 2900mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 100mL 2hr + fluorouracil 2000mg/m2 2800mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-06 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-16 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-04-27

  • 2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.

  • The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

2023-03-30

  • Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.

  • Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.

  • No medication reconciliation issue identified.

2023-03-07

  • The patient is undergoing FOLFOX NIPS treatment for the second time during this hospital stay. There are no apparent complaints of adverse reactions following the patient’s last treatment.
  • Potassium supplementation is currently administered appropriately to manage low serum K level (2023-03-06 3.0mmol/L) in this patient.

2023-02-17

  • The patient undergos palliative chemotherapy with a combination of mFOLFOX IV/IP C/T every two weeks for a total of 12 cycles since this hospital stay. After the first 6 cycles the patient will undergo an abdominal CT scan to evaluate the response to treatment.
  • Lab data 2023-02-16 showed grossly normal readings, and the patient’s TPR and blood pressure vital signs have remained stable throughout his hospitalization as of now.
  • Megestrol is appropriately used as an appetite stimulant in this patient with poor appetite and unintended weight loss.

701173522

230427

{not completed}

[exam findings]

[surgical operation]

  • 2019-08-26
    • Diagnosis: Malignant ovary neoplasm with peritoneal carcinomatosis
    • PCS code: 73043B
    • Finding
      • ascite (-)
      • small bowel adhesion (++)
      • tumor (-)
  • 2019-07-15
    • Diagnosis: Malignant ovary neoplasm
    • PCS code: 73014B
    • Finding: mutiple tumor seeding over s7, right diaphragm, left paracolic gutter, pelvis, surface of urinary bladder, ascending colon, and sigmoid colon
  • 2019-07-15
    • Diagnosis: Ovarian cancer
    • PCS code: 80418B
    • Finding:
      • Supraumbilical midline vertical skin incision.
      • Uterus: 6x3 cm, tense contact with bladder, no obvious tumor noted
      • Adnexa:
        • Lt: 3x2 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
        • Rt: 4x3 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
      • CDS: invisible due to tumor mass occupied
      • Ascites: little
      • Bilateral paraaortic and pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: with multiple hard, variablesized millitary nodules
      • Liver: with rough surface
      • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
      • After the operation, HIPEC was performed.
      • Residue tumor: multiple millitary tumors, diameter about 0.1 cm, over peritoneal wall, small intestine and colon
      • Estimated blood loss: 850ml (include ascites)
      • Blood transfusion: nil
      • Complication: nil
  • 2019-04-11
    • Diagnosis: Maliganat cervix uteri neoplas
    • PCS code: 47080B
    • Finding:
      • peritoneal carcinomatosis, PCI: 17/39, small bowel PCI: 4
      • malignant ascites(+), about 2600ml
      • omentum cake(+)
  • 2017-07-15
    • Diagnosis: Malignant ovary neoplasm
    • PCS code: 50010C
    • Finding: bilateral ureter was indwelled with 4Fr. catheter under direct vision

[chemotherapy]

  • 2023-04-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-12 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-29 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-03-22 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-03-08 - topotecan 3.75mg/m2 5.0mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-01-18 - bevacizumab 7.5mg/kg 450mg NS 250mL 90min + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-26 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-05 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-14 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-12 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-25 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-07-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-06-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-05-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-05-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-04-20 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-03-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-03-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-02-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-24 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-12-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-09 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-10-19 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-06 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-08-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-07-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-07 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-03-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-02-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-01-04 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-12-07 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-26 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-05 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-09-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Medication

  • Lynparza (olaparib 150mg) 2# BIDCC PO
    • 2023-04-12 ~ undergoing (OPD)

[assessment]

  • The patient experienced severe neutropenia after their last chemotherapy session on 2023-04-19, with the low WBC count observed on 2023-04-24. G-CSF (filgrastim) 300ug QD for 14 days has been prescribed since 2023-04-24 to address this issue. To date, the WBC count has improved slightly, increasing from a low of 260/uL to 420/uL.
    • 2023-04-27 WBC 0.42 x10^3/uL
    • 2023-04-26 WBC 0.30 x10^3/uL
    • 2023-04-25 WBC 0.26 x10^3/uL
    • 2023-04-24 WBC 0.33 x10^3/uL
    • 2023-04-19 WBC 12.02 x10^3/uL
    • 2023-04-12 WBC 3.56 x10^3/uL
  • The patient has received blood transfusions for their anemia, with 2 units of L-PRBC administered on 2023-04-24 at around 20:00, 1 unit at around 23:00, and an additional 2 units on 2023-04-27 at around 13:00.
    • 2023-04-27 HGB 7.6 g/dL
    • 2023-04-26 HGB 8.1 g/dL
    • 2023-04-25 HGB 8.6 g/dL
    • 2023-04-24 HGB 7.6 g/dL
    • 2023-04-19 HGB 8.8 g/dL
    • 2023-04-12 HGB 10.2 g/dL
  • The patient’s platelet count has shown a steep drop and, as of now, there is no obvious sign of recovery. If the risk of bleeding is high, platelet transfusion may be necessary.
    • 2023-04-27 PLT 18 x10^3/uL
    • 2023-04-26 PLT 28 x10^3/uL
    • 2023-04-25 PLT 47 x10^3/uL
    • 2023-04-24 PLT 7 x10^3/uL
    • 2023-04-19 PLT 91 x10^3/uL
    • 2023-04-12 PLT 184 x10^3/uL

700618096

230426

[past history] - 2023-04-20 admission note

  • Hypertension for 10 years with regular medication control.

  • DM with triopathy for 10+ years with regular OHA, insulin control.

  • Asthma: Asthma since young with regular OPD f/u.

  • Operation history: Appendectomy 10 yrs ago.

  • Denied history of Hypertension, DM, asthma

  • Denied any operation, accident and other medical Hx.        

[allergy]

  • Primperan (metoclopramide): other

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-04-24 Tc-99m MDP bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, and S-I joints.
  • 2023-04-21 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2023-04-21 Nasopharyngoscopy
    • Findings: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
    • Diagnosis: suspect functional dysphonia, or medication-related dysphonia.
  • 2023-04-20 CXR
    • There are few nodular opacities projecting in right lung that may be metastases. Please correlate with CT.
  • 2022-10-21 CT - abdomen (at other hospital)
    • Findings
      • Fatty liver
      • post-operative change of colon
      • no definite lesion in pancreas, spleen, bilateral adrenal glands, kidneys
      • soft tissue lesions within pelvic cavity, peritoneal, metastases are considered
      • no definite lymphadenopathy
      • no ascites
    • Impression:
      • Peritoneal metastases
      • Fatty liver

[consultation]

  • 2023-04-21 Ear Nose Throat
    • Q
      • The 37 y/o woman has Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX. Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum. Then she received Avastin plus FOLFIRI * 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver. This time, admitted for chemotherapy with FOLFOXIRI.
      • For hoarse was noted for 3 weeks, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • Scope: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
      • Impression: suspect functional dysphonia, or medication-related dysphonia.
      • Plan: Please give Broen-C 2# TID and arrange ENT OPD follow-up after discharge.

[lab data]

  • 2023-04-12 Anti-HBc Nonreactive
  • 2023-04-12 Anti-HBc-Value 0.08 S/CO
  • 2023-04-12 HBsAg Nonreactive
  • 2023-04-12 HBsAg (Value) 0.49 S/CO
  • 2023-04-12 Anti-HCV Nonreactive
  • 2023-04-12 Anti-HCV Value 0.06 S/CO

[MedRec]

  • 2023-04-06 SOAP Hemato-Oncology
    • S
      • s/p sigmoidectomy with LND on 2020-03-20
      • s/p Port-A on 2020-04-10
      • s/p adjuvant chemtoehrapy with FOLFOX from 2020-04-20 to 2020-10-28 -> PD over RML of lung and LN of left iliac chain, Stage IVA, rcT0N1bM1a
      • s/p Laparoscopic plevic LND on 2022-03-11
      • s/p A-FOLFIRI
      • s/p Laparoscopic intran-abdominla excision of peritoneal carcinomatosis on 2023-01-09 -> PD over lung, liver, bilateral iliac LNs and peritoneal carcinomosis by 2023-03-16 PET-CT, M1c, Stage IVB
    • P
      • Admission for FOLFOXIRI
  • 2023-04-06 SOAP Hemato-Oncology
    • S
      • Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX.
      • Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum.
      • Then she received A-FOLFIRI 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver.
    • P
      • Request medical records and report
  • 2017-12-14 SOAP Hemato-Oncology
    • O
      • 2017/12/07 Ferritin:5.2 ng/mL
      • Start iron therapy (20171214)
    • A
      • Iron deficiency anemia, unspecified [D50.9]
      • Thrombocytopenia [D69.6]
    • Prescription
      • Foliromin (sodium ferrous citrate 50mg) 1# QN 14 days
  • 2017-12-07 SOAP Hemato-Oncology
    • S
      • Referred from clinic on account of microcytic anemia
      • suspected thalassemia in her sister
      • Unexplained purpura
    • O
      • BH 168 BW 66
      • slight pale skin
    • Diagnosis
      • Anemia, unspecified [D64.9]
      • Thrombocytopenia [D69.6]

[assessment]

  • The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.

  • Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.

  • The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.

    • 2023-04-25 PLT 83 *10^3/uL
    • 2023-04-24 PLT 95 *10^3/uL
    • 2023-04-11 PLT 100 *10^3/uL
    • 2022-12-24 PLT 143 *10^3/uL
    • 2020-12-28 PLT 160 *10^3/uL

701137983

230426

[diagnosis] - 2023-04-25 admission note

  • pancreatic head carcinoma,cT4N0M0, stage III, Dx in June 2022 , obstructive jaundice s/p PTGBD on 20220613
  • Type 2 diabetes mellitus without complications
  • Chronic obstructive pulmonary disease, unspecified
  • Obstruction of bile duct

[past history] - 2023-04-25 admission note

DM, HTN, CHF, COPD, Hyperlipidemia, Asthma                                                    

[allergy]

  • penicillin: rash;

[family history]

no hypertension, diabetes mellitus, cancer history

[exam finding]

  • 2023-04-03 KUB
    • Fecal material store in the colon.
    • S/P PTGBD with pigtail catheter implantation
  • 2023-03-13 CXR
    • Port-A catheter inserted into RA via left subclavian vein.
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Nodular opacitiy projecting over Rt lower lung zone due to nipple shadow
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/ supine position
    • S/p PTGB drainage
  • 2023-03-13 ECG
    • Sinus tachycardia with Premature supraventricular complexes
    • ST & T wave abnormality, consider inferior ischemia
  • 2023-03-13 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Diagnosis
      • Failed Cholangiography
      • Pancreatic cancer s/p PTGBD
    • Suggestion
      • EUS/CDS or Rendevous ERCP
  • 2023-03-09 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter.
      • Obstruction of CBD.
  • 2023-03-08 SONO - abdomen
    • Post PTGBD with dilated IHD and CBD
    • Dilated main pancreatic duct
    • Pancreatic head tumor
  • 2023-03-08 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade D
      • Esophageal ulcers and erosions, lower to middle esophagus
      • Superficial gastritis, s/p CLO test
      • Gastric subepithelial lesion, anterior wall of upper body
    • Suggestion
      • PPI Q12H IV
      • EUS
  • 2023-03-06 ECG
    • Sinus tachycardia
    • Premature atrial complexes
    • Premature ventricular complexes
    • Marked ST abnormality, possible inferior subendocardial injury
    • Abnormal ECG
  • 2023-02-18, 2022-11-24 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • S/P pigtail catheter implantation at the gallbladder .
  • 2023-02-01 CT - abdomen
    • History:
      • 20220610 US: R/O pancreatic head tumor with obstructive jaundice.
      • 20220624 CT:Pancreatic head cancer, cT4N0M0, stage:III
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings: Comparison prior CT dated 2022/11/24.
      • Prior CT identified an ill-defined poor enhancing mass measuring 3.5 cm in the pancreatic head, causing marked dilatation of the bile duct and pancreatic duct, is noted again, mild increasing in size to 4 cm.
        • It is c/w adenocarcinoma of the pancreatic head S/P C/T with stable disease.
        • Prior CT identified tumor direct invasion the celiac trunk, superior mesenteric artery, and the trifurcation of superior mesenteric vein, splenic vein, and portal vein is noted again, stationary.
      • Prior CT identified liver metastasis 1.4 cm in S5 of the liver is noted again, mild decreasing in size and poor margination that is c/w liver metastasis S/P C/T with partial response. Follow up is indicated.
      • There are two cyst 1.7 cm and 0.5 cm in S6 liver.
        • Please correlate with sonography.
      • S/P PTGBD with pigtail catheter implantation
    • Impression:
      • Pancreatic head cancer S/P C/T show stable disease.
      • Liver metastasis in S5 S/P C/T show partial response.
  • 2023-01-31 SONO - abdomen
    • Post PTGBD
    • Dilated main pancreatic duct
    • Rule out pancreatic head tumor
  • 2022-11-24 CT - abdomen
    • History and indication: 71 y/o female, a pt of pancreatic head carcinoma, cT4N0M0, stage III
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of pancreatic head cancer.
      • S/P PTGBD. Right liver cyst (2.0cm).
  • 2022-09-08 Ocular fundus photography
    • fundus c/d 50% ou
    • moderate NPDR ou
      • ChatGPT: NPDR in the context of ocular fundus photography stands for Non-Proliferative Diabetic Retinopathy. There are two main stages of diabetic retinopathy:
        • Non-Proliferative Diabetic Retinopathy (NPDR): This is the early stage of diabetic retinopathy and is characterized by changes in the retinal blood vessels, including microaneurysms (small outpouchings), retinal hemorrhages (bleeding), and retinal edema (swelling). In some cases, NPDR may progress to a more advanced form called diabetic macular edema (DME), which is characterized by swelling in the central part of the retina (macula) and can lead to vision loss.
        • Proliferative Diabetic Retinopathy (PDR): This is the more advanced stage of the disease and is characterized by the formation of abnormal new blood vessels on the surface of the retina or the optic disc. These new vessels are fragile and prone to bleeding, which can lead to further complications like vitreous hemorrhage, retinal detachment, or severe vision loss.
  • 2022-06-30 Patho - pancreas biopsy
    • Pancreatic head, EUS-FNB — Ductal adenocarcinoma, moderately differentiated
    • The sections show a picture of ductal adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells with abundant clear cytoplasm, embedded in fibrous stroma. Glandular differentiation and mucin secretion are present. Tumor necrosis can be identified also.
  • 2022-06-30 Cell Block Cytology
    • pancreas, SMEAR and CELL : adenocarcinoma;
    • SMEAR and CELL: show clusters of adenocarcinoma
  • 2022-06-30 Needle Aspiration Cytology - pancreas
    • pancreas, FNA: adenocarcinoma;
    • Smears show clusters of adenocarcinoma
  • 2022-06-30 Endoscopic Ultrasonography, EUS
    • suspected pancreatic head cancer, T4N1Mx, s/p EUS/FNB
    • reflux esophagitis, LA-A
  • 2022-06-29 CXR
    • Atherosclerosis of the aorta.
  • 2022-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
      • M-mode (Teichholz) = 74.7 ~ 61.2
    • Conclusion
      • Normal AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Normal LV wall motion
      • No PR, trivial TR, normal IVC size
  • 2022-06-27 Flow-volume loops
    • Mild obstructive ventilatory impairment
  • 2022-06-24 CT - liver, spleen, biliary duct, pancreas
    • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage): T4N0M0, stage III
  • 2022-06-10 ECG
    • Sinus rhythm with 1st degree A-V block
    • Cannot rule out Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-06-10 CXR
    • Presence of ileus.
  • 2022-06-10 SONO - abdomen
    • diagnosis
      • suspicious, pancreatic head tumor with obstructive jaundice
      • fatty liver, mild
    • suggestion
      • correlate with other image study and tumor markers
  • 2022-03-17 Optical Coherence Tomography
    • fundus c/d 50% ou
    • moderate NPDR ou
  • 2022-02-14 CXR
    • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte
  • 2021-03-15 CXR
    • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • moderate enlarged cardiac silhoutte
    • ……

[consultation]

  • 2022-06-24 General and Gastrointestinal Surgery
    • Q
      • For operation evaluation
      • This 71 y/o female has hitory of DM, HTN, CHF, COPD, Hyperlipidemia, Asthma under regular follow up at our CV, Meta, and CM’s OPD and this time she came our GI’s OPD for epigastric dullness pain for several weeks and jaundice, where PE and Lab data were surveyed and abdomen echo was also done and pancreatic head tumor with obstructive jaundice was suspected, so referal to ER for Covid-19 PCR checking and admission to GI’s ward for further management was done. However, the PCR result at ER showed positive result with CT value 17, the patient was admitted to our quarantine ward for Covid-19 infection. She transfer to GI ward on 2022/06/24. Abdominal CT was arranged on 2022/06/24. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • S:
        • The patient was suspected pancreatic head tumor with obstructive jaundice. Surgical evaluation is consulted.
      • O:
        • vital signs: stable, no fever
        • abdomen: a PTGBD over R’t abdomen with bile content, soft, ovoid, decrease bowel sound, no tenderness, no Murphy’s sign
        • lab data: see chart
      • A:
        • Pancreatic head Ca, cT2N0M0, stage IB
      • P:
        • Please arrange echocardiogram & test
        • If heart function & PFT is OK, pylorus preserving pancreaticoduodenectomy is suggested next week.
  • 2022-06-13 Radiation Oncology
    • Q
      • For pancreat cancer with on PTGBD. (PTGBD: percutaneous transhepatic gallbladder drainage)
    • A
      • According to the clinical condition and imaging findings, PTGBD is indicated.

[MedRec]

  • 2022-07-05 SOAP Hemato-Oncology
    • S
      • PH:
        • COVID-19, virus identified
        • Chronic systolic (congestive) heart failure
        • Type 2 diabetes mellitus without complications
        • Chronic obstructive pulmonary disease
      • weight loss (+) (10kg in 2~3 Mo )
      • suffered from initial presentation of genealized jaundice in June 2022
      • referred to our clinic on 7/5 22 for pre-Op neoadjuvant C/T
      • ancreatic head carcinoma, cT4N0M0, stage III, Dx in June 2022
      • obstructive jaundice s/p PTGBD on 6/13 22.
      • explain to pt about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 6 or more then do abd CT for response / Op evaluation (7/5 22).
      • HBsAg, anti-HBc (6/11 22): negative.
      • will give pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6 (7/5 22).
      • Adm 1 wk later on 7/15 22 for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6.
  • 2017-05-22 SOAP Cardiology
    • Diagnosis
      • Chronic systolic (congestive) heart failure [I50.22]
      • Essential (primary) hypertension [I10]
    • Prescription
      • Hexal (carvedilol 25mg) 1# QD 28 days
      • Blopress (candesartan 8mg) 0.5# BID 28 days
      • Aldactin (spironolactone 25mg) 1# QD 28 days
  • 2017-05-22 SOAP Chest Medicine
    • Diagnosis
      • Pulmonary TB, unspecified, by culture (+) [A15.0]
      • Acute respiratory failure [J96.00]
      • Pneumonia, unspecified organism [J18.9]
      • Congestive heart failure [I50.22]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • hyperuricemia [E79.0]
    • Prescription
      • NovoNorm (repaglinide 1mg) 1# TIDAC 7 days
      • colchicine 0.5mg 1# QD 14 days
      • Vit B6 (pyridoxine 50mg) 1# QD 14 days
      • Euricon (benzbromarone 50mg) 1# QD 14 days
      • Through (sennosides) 12mg 1# HS 14 days
      • Rifinah (RIF 300mg + INH 150mg) 2# QD 14 days
      • pyrazinamide 500mg 2.5# QD 8 days
      • Welizen (famotidine 20mg) 1# BID 14 days
      • Epbutol (ethambutol 400mg) 2# QD 8 days
  • 2017-03-25 SOAP Metabolism
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Trajenta (linagliptin 5mg) 1# QD 4 days
      • Glucobay (acarbose 100mg) 1# TIDAC 4 days
      • Uformin (metformin 500mg) 1# TIDCC 4 days
      • Kludone (gliclazide 60mg) 1# BID 4 days
      • Uretropic (furosemide 40mg) 1# QD 4 days

[chemoimmunotherapy]

  • 2023-04-25 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-04-03 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-03-03 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-02-13 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-29 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-08 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-11-11 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-10-20 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 215mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-09-12 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-08-26 - oxaliplatin 80mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3450mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-08-10 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-07-18 - oxaliplatin 60mg/m2 80mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

[note]

  • Pancreatic Adenocarcinoma NCCN Evidence Blocks Version 1.2022 - May 3, 2022, p39,41
    • neoadjuvant therapy
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
      • Only for known BRCA1/2 or PALB2 mutations
        • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
        • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
    • adjuvant therapy
      • preferred regimens
        • Modified FOLFIRINOX (category 1)
        • Gemcitabine + capecitabine (category 1)
      • other recommended regimens
        • Gemcitabine (category 1)
        • 5-FU + leucovorin (category 1)
        • Continuous infusion 5-FU
        • Capecitabine (category 2B)
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU
  • Modified FOLFIRINOX chemotherapy for pancreatic cancer (UpToDate 20220719)
    • Cycle length: 14 days.
    • Regimen
      • Oxaliplatin
        • 85 mg/m2 IV
        • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
        • Day 1
      • Leucovorin
        • 400 mg/m2 IV
        • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
        • Day 1
      • Irinotecan
        • 150 mg/m2 IV
        • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
        • Day 1
      • Fluorouracil (FU)
        • 2400 mg/m2 IV
        • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
        • Day 1
    • Pretreatment considerations:
      • Emesis risk
        • HIGH (greater than 90% frequency of emesis).
      • Prophylaxis for infusion reactions
        • Although infusion reactions have been reported with oxaliplatin, there is no recommended standard premedication for this regimen.
      • Vesicant/irritant properties
        • Oxaliplatin and FU are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
      • Infection prophylaxis
        • Primary prophylaxis with G-CSF is not warranted. However, given the risk of grade 3 or 4 neutropenia (46%), primary prophylaxis with G-CSF is used at many institutions, especially when this regimen is used in the adjuvant setting.
      • Dose adjustment for baseline liver or renal dysfunction
        • A lower starting dose of oxaliplatin and irinotecan may be needed for severe renal insufficiency. A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
        • NOTE: We do not recommend administration of FOLFIRINOX unless serum bilirubin is normal.
      • Maneuvers to prevent neurotoxicity
        • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
      • Cardiac issues
        • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
        • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, electrocardiographic changes, and cardiomyopathy.
    • Monitoring parameters:
      • CBC with differential and platelet count prior to each treatment.
      • Electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
      • Irinotecan is associated with early and late diarrhea, both of which may be severe. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine during later cycles. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed.
      • Assess changes in neurologic function prior to each treatment.
    • Suggested dose modifications for toxicity:
      • Myelotoxicity
        • Do not retreat unless neutrophil count is >=1500/microL and platelets are >=75,000/microL. The following dose reduction guidelines for hematologic toxicity are recommended; several of these are based upon recommendations in the original FOLFIRINOX protocol.
        • Neutropenia
          • If day 1 treatment delayed for granulocytes is <1500/microL or febrile neutropenia or grade 4 neutropenia >7 days: Reduce irinotecan dose to 120 mg/m2. For second occurrence: Reduce oxaliplatin dose to 60 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of granulocytes <1500/microL on day 1, discontinue treatment. For grade 4 neutropenia >7 days during treatment or febrile neutropenia, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
        • Thrombocytopenia
          • If day 1 treatment delayed for platelet count <75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 120 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of platelets <75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • Diarrhea
        • Do not retreat with FOLFIRINOX until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 120 mg/m2. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the continuous FU dose to 75% of original dose. Discontinue treatment for third occurrence.
        • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
      • Mucositis or hand-foot syndrome
        • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
      • Pulmonary toxicity
        • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
      • Neurologic toxicity
        • For persistent grade 3 paresthesias/dysesthesias or transient grade 2 symptoms lasting >7 days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
        • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
      • Cardiotoxicity
        • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
      • Other toxicity
        • Any other toxicity >=grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
        • For other nonhematologic toxicities, if grade 2, hold treatment until <=grade 1; if grade 3 or 4, hold treatment until <=grade 2.
      • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2023-04-26

  • There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.

  • The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.

    • 2023-04-08 HbA1c 8.3 %
    • 2023-01-14 HbA1c 8.6 %
    • 2022-10-20 HbA1c 7.4 %
    • 2022-07-25 HbA1c 7.0 %
    • 2022-04-30 HbA1c 8.3 %

2022-07-17

  • UGT1A1 genotyping result is not found in HIS5, please monitor if early and/or late (irinotecan caused) diarrhea occurs
  • There has been an upward trend in HbA1c levels over the past 12 months, a follow-up update might be considered.
    • 2022-04-30 HbA1c 8.3 %
    • 2022-02-05 HbA1c 8.2 %
    • 2021-11-13 HbA1c 7.4 %
    • 2021-08-21 HbA1c 7.0 %
  • Since this hospitalization, the level of blood sugar remains high
    • 2022-07-19 06:06 215 mg/dL
    • 2022-07-18 16:18 191 mg/dL
  • As for this patient has been taking metformin (DC for now), vildagliptin (DPP4i), glimepiride (sulfonylurea), and acarbose (alpha-glucosidase inhibitors) for a considerable period of time. Basal insulin might be an optional add-on if HbA1c rises above 8.5% and AC glucose rises above 250 mg/dL for most of the days.
  • A c-peptide test is also recommended for her.

700074348

230424

[exam findings] (not completed)

  • 2023-04-03 PET scan
    • In comparison with the previous study on 2022-02-22, some glucose hypermetabolism lesions in the retroperitoneum and in the left lower pelvic region come to less evident or disappear; several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen, however, are noted. The nature is to be determined (metastatic disease in progression or even another primary malignancy), suggesting biopsy (the soft tissue in RLQ of abdomen) for further investigation,.
    • Glucose hypermetabolism lesions in bilateral pulmonary hilar and mediastinal lymph nodes and in bilateral axillary lymph nodes, probably reactive nodes, suggesting follow-up.
    • Increased FDG uptake in the right lobe of the liver and in two right ribs, highly suspected malignancy with distant metastases.
    • Glucose hypermetabolism in the left shoulder, compatible with arthritis.
    • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases, by this F-18-FDG PET/CT scan.
  • 2022-10-31 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet, in whole body survey.
    • IMPRESSION:
      • No strong evidnece of bone metastasis.
      • Suspected benign lesions in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet.
  • 2022-09-17 MRI - L-spine
    • Past Hx: gouty arthritis; steroid(+); oral cancer. Right tonsillar cancer with right neck lymph node metastasis, T1N2cM0, stage IVA s/p concurrent chemoradiotheraphy in 2006. 20220819: LBP and right sciatica for 6 months; ongoing C/T;
    • Findings
      • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3.
      • Decreased vertebral body height, end-plate degeneration, disc collapse with severe general bulging, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L3-4, much more severe on left side.
      • End-plate degeneration, disc collapse with general bulging and right lateral focal protrusion, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L4-5, much more severe on right side.
      • Mild general bulging disc at L5-S1.
      • No intramedullary lesion.
      • Mild scoliosis of L-spine.
      • A 17-mm T2-hyperintense cyst at left kidney.
    • IMP: Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L3-4 and L4-5 (with right HIVD).
  • 2022-06-28 CT - abdomen
    • Left renal cyst (1.4cm).
    • A cyst (9mm) at LLL.

[consultation]

  • 2023-04-24 Diagnostic Radiation
    • Q
      • This is a 58-year-old male with underlying history of:
        • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
        • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
        • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
        • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
        • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
      • On follow-up PET on 2023/04/03, report showed:
        • several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen
        • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases was impressed
      • Therefore, this time we would really need your expertise in performing CT-guided biopsy at RLQ abdomen soft tissue mass for this patient. Thanks a lot in advance!
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2021-09-29 Radiation Oncology
    • Q
      • For RT evaluation
      • This is a 56-year-old male patient with a history of
        • right tonsillar cancer, T1N2cM0, stage IVA, status post concurrent chemoradiotheraphy in 2006,
        • right anterior mouth floor squamous cell carcinoma in situ, status post excision and revisional wide excision in 2010,
        • right mouth floor cancer, pT1N0cM0, status post wide excision and right selective neck dissection over level 1~3 in 2013,
        • left mouth floor cancer cT4aN0M0, status post induction chemotherapy and surgical excision in 2016, ypT1N1,
        • right lower neck tumor recurrence s/p right radical neck dissection on 2020-9-16, post-op CCRT completed on 2020-11-06, s/p oral ufur,
        • Left pelvic lesion s/p CT guided biopsy on 2021-03-12 (pathology: Metastatic squamous cell carcinoma, poorly differentiated), PET also revealed a new nodular lesion in RUQ of abdomen s/p CCRT for pelvic lesion (completed on 2021-05-17).
      • This time, he came to our hospital due to left lower gingiva lesion noted for weeks. Therefore, he came to our OPD for help. Abnormal painful leukoplakia-erythroplakia lesion at the left mandible was noted at OPD. Biopsy was done for left lower gingival lesion, and the pathology report was SCC. He received operation of oral tumor wide excision + marginal mandibulectomy +- local flap reconstruction on 2021-09-24, and the pathology was pending.
      • Also, pelvic and abdomen CT f/u on 2021-09-06 revealed A soft tissue lesion (2.4cm) at right perirenal region r/o tumor seeding and Enlarged LNs (up to 2.6cm) at retroperitoneum r/o metastases. Urologist was consulted and suggested CCRT.
      • Therefore, we need your expertised for further RT management for the patient.
    • A
      • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
      • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
      • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
      • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
      • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
    • P: Radiotherapy is indicated for this patient with the following indicators: metastatic lesions over the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
      • Goal: palliation
      • Treatment target and volume: the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and would like to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-10-01.
  • 2020-09-01 Colorectal Surgery
    • Q
      • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
    • A
      • S: Consult for left pelvic nodule.
      • O: CT > A LN (0.8cm) at left pelvic cavity.
        • with suspect adhesion to vessel and sacal bone
        • Also nodule lesion over right inguinal region.
      • A: Multiple PET lesion
      • P:
        • please arrange colonoscopy to check colon tumor
        • high risk for surgical remove this nodule. and PET also show multiple lesion.
        • If no colonic lesion is seen, suggest medical treatment first (by neck etilogy)
  • 2020-09-01 Urology
    • Q
      • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
    • A
      • 55M with left pelic LNs
      • S: oral cancer, s/p op,
      • O: PET and CT: showed one 1cm LN near left internal ileac artery
      • A: oral cancer, stage IVa
      • P:
        • oral cancer with LNs mets is highly suspected
        • difficult position for CT-guided biopsy
        • please check PSA, U/A, and urine cytology to r/o prostate cancer and bladder cancer

[chemotherapy]

  • 2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-30

  • 2022-08-01

  • 2022-07-01

  • 2022-05-31

  • 2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + 1S 250mL
  • 2021-11-05

  • 2021-10-29

  • 2021-05-11

  • 2021-05-04

  • 2021-04-28

  • 2020-11-03

  • 2020-10-27

  • 2020-10-20

[assessment]

  • On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.

  • 2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.

700267861

230424

[exam findings]

  • 2023-04-11 Patho - kidney biopsy
    • Kidney, left, CT-guided biopsy — Invasive urothelial carcinoma, high-grade
    • The sections show following features:
      • Histologic type: Urothelial carcinoma, invasive
      • Histologic grade: High-grade
      • Tumor configuration: Nodular
      • Muscularis propria: Absent
      • Lymphovascular invasion: Not identified
    • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
  • 2023-04-10 CT - abdomen
    • History and indication: Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma, suspected renal cell carcinoma
    • With and without-contrast CT of abdomen-pelvis revealed:
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
      • Some LNs at retroperitoneum.
      • Liver cysts (up to 1.5cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
  • 2023-04-01 CXR
    • Blunting of left CP angle
    • Borderline enlarged cardiac sihoutte
  • 2023-04-01 EXG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
    • Abnormal ECG
  • 2023-03-27 SONO - neurology
    • Chronic renal parenchymal disease, mild degree
    • Suspected left renal pelvic mass lesion with hydronephrosis
  • 2023-03-23 CT - abdomen
    • Indication: nausea without vomiting and abdominal pain for half a monthalso, mild dyspnea was notedwent to Feng Rong Hospital, ileus and mild pneumonia was told
    • Without contrast enhancement CT of abdomen shows:
      • Infiltrating mass lesion in retroperitoneum, possibly derived from left ureter. Imperceptible margin with adjacent kidney and aorta. Regional enlarged lymph nodes noted.
      • Left hydronephrosis.
      • No ascites or extraluminal free air.
      • No evidence of bowel obstruction.
      • No bony destructive lesion on these images.
    • Impression
      • Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma; DDx: renal cell carcinoma
      • Suspect regional lymph node metastsis
  • 2023-03-23 KUB
    • Degenerative change of the lumbar spine
  • 2023-03-23 ECG
    • ST & T wave abnormality, consider anterolateral ischemia

[consultation]

  • 2023-03-24 Urology
    • Q
      • nausea without vomiting and abdominal pain for half a month
      • also, mild dyspnea was noted
      • went to Feng Rong Hospital today, ileus and mild pneumonia was told
      • PH: DM, HF
      • OP: hysterectomy 50 yrs ago, left inguinal hernia, s/p op 10 yrs ago
      • NKA
    • A
      • please treat her ileus and pneumonia first, due to advanced age and poor condition, she may not fit for further diagnostic or therapeutic intervention for cancer currrently.

[MedRec]

  • 2023-04-21 SOAP Hemato-Oncology
    • Con’s:E4V5M6
    • 2023/04/11 PATHO - kidney biopsy
      • Invasive urothelial carcinoma, high-grade
        • Histologic type: Urothelial carcinoma, invasive
        • Histologic grade: High-grade
        • Tumor configuration: Nodular
        • Muscularis propria: Absent
        • Lymphovascular invasion: Not identified
      • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
    • 2023/04/10 CT: ABD
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
    • 2023/03/23 CT: ABD
      • Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma
      • Suspect regional lymph node metastsis
    • Lab
      • 2023/04/10
        • HBsAg = Nonreactive;
        • Anti-HBc = Reactive;
        • Anti-HCV = Nonreactive;
  • 2023-04-07 SOAP Hemato-Oncology
    • Past hx : hypertension, hyperlipidemia, T2DM, renal tumor
    • Allergy : NKDA
    • She was treated at Cathay hospital for her CV problem.
    • preliminary impression: R10.9 Unspecified abdominal pain
    • Discussion about tissue proof
    • Inform the patients son and sons wife about the risk and benfit of biopsy
  • 2023-03-23 SOAP Emergency
    • preliminary impression: Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma
    • lab data
      • 2023/03/23 21:22 BUN = 31 mg/dL;
      • 2023/03/23 21:22 Creatinine = 1.51 mg/dL;

==========

2023-04-01

  • On 2023-03-23, a CT scan revealed a retroperitoneal tumor involving the aorta and left kidney, with a differential diagnosis of left urothelial carcinoma or renal cell carcinoma. Regional lymph node metastasis is also suspected.
  • Further work on staging is pending. Family members requested not to inform the patient about the diagnosis until the pathology report is confirmed.
  • There are no medication reconciliation issues after checking the PharmaCloud database.

700287641

230424

[diagnosis] - 2023-04-22 discharge note

  • Left breast cancer, rpT4bN1M0, stage IIIB,ER (+): +, PR (+): +, HER-2/Neu +:  Negative (1+), Ki-67: 10-20 %. ECOG:1.
  • Right breast invasive carcinoma, pT2N3aM0, stage IIIB. ER (+), PR(-), Her2/neu: negative(score=0), Ki-67:30 %. ECOG:1.
  • For adjuvant chemotherapy with Taxotere
  • Nasopharyngeal carcinoma, cT1N0M0, stage I
  • Essential (primary) hypertension

[exam findings]

  • 2023-03-11 Anoscopy

    • mild mixed hemorrhoids, perianal dermatitis
  • 2023-02-09 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 20) / 95 = 78.95%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Gr II LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild MR; mild TR; mild PR.
  • 2022-12-22 Nasopharyngoscopy

    • Findings
      • bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
      • a few watery discharge at left posterior nasal cavity floor
    • Diagnosis/Conclusion
      • NPC s/p treatment, no evidence of recurrence
  • 2022-11-24 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 20.0) / 95.9 = 79.14%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2022-11-17 SONO - abdomen

    • Right renal cyst (0.87x0.98cm).
  • 2022-10-26 PET scan

    • Glucose hypermetabolic lesions in the right axillary lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in the right mediastinal lymph nodes, the nature is to be determined (metastatic or reactive nodes ?), suggesting biopsy for further investigation.
    • Increased FDG uptake in the left pulmonary hilar region, probably reactive nodes.
    • Left breast cancer s/p treatment with tumor recurrence and right axillary lymph nodes metastases, by this F-18 FDG PET/CT scan.
  • 2022-10-18 Patho - breast mastectomy with regional lymph nodes

    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right, modified radical mastectomy —- Invasive carcinoma of no special type
      • Resection margins, ditto — Free of tumor invasion
      • Skin and nipple, ditto — Free of tumor invasion
      • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (3/3) with extracapsular extension (3/3)
      • Lymph node, R’t axillary non-SLN, MRM — Tumor metastasis (10/10) with extracapsular extension (8/10)
      • AJCC Pathologic Anatomic Stage — pT2N3a, if cM0, stage IIIC; Prognostic Stage — Stage IIIB
    • MACROSCOPIC EXAMINATION
      • Breast: 21 x 13.3 x 3.7 cm
      • Skin: 18 x 5.1 cm, normal appearance
      • Nipple: 1.2 x 1.2 cm, mild retraction
      • Tumor: 3 x 2.2 x 2.1 cm
      • Resection margins: Free, 0.7 cm away from closest base
      • Lymph node: R’t axillary sentinel and non-sentinel lymph node
      • Representatively embedded for sections as: A1-A2: Nipple + skin + tumor, A3-A8: Tumor, X1: tumor + base and X2: four peripheral margins and B1-B2: R’t axillary LNs [Reference F2022-00487, FSA1-FSA2 and A: R’t axillary sentinel LN]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3 x 2.2 x 2.1 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]
      • Margins: Free, 0.7 cm from closest base margin
      • Lymph node, R’t axillary SLN: Tumor metastasis (3/3) with extracapsular extension (3/3)
      • Lymph node, R’t axillary non-SLN: Tumor metastasis (10/10) with extracapsular extension (8/10)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: present, multiple
      • Perienural invasion: present
      • Immunohistochemistry: E-cadherin(+)
  • 2022-10-18 Frozen Section

    • R’t axillar sentinel lymph nodes, frozen section — Tumor metastasis (3/3)
  • 2022-10-17 Flow Volume Loop

    • mild obstructive impairment
  • 2022-10-07 Patho - breast biopsy (no need margin)

    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0), Ki-67(30 %), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-10-07 SONO - breast

    • S/P left mastectomy.
    • Right subareolar irregular tumor with regional skin edema/thickening. Suggest biopsy.
    • BI-RADS: Category 4: suspicious abnormality-biopsy should be considered.
  • 2022-10-07 Mammography

    • Impression:
      • S/P left mastectomy.
      • Right periareolar skin thickening, suggest further study.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2022-08-25 SONO - abdomen

    • Right renal cyst (1.08x1.14cm).
  • 2022-08-11 Nasopharyngoscopy

    • Findings: bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
    • Diagnosis/Conclusion: NPC s/p treatment, no evidence of recurrence
  • 2022-06-30 ENT Hearing Test

    • Tymp RE type C, LE type B
    • PTA:
      • Reliability FAIR
      • Average RE 74 dB HL, LE 81 dB HL
      • RE moderately severe to profound HL
      • LE severe to profound MHL
  • 2022-06-08 Neurosonology

    • Moderate to severe atheromatous lesion in R CCA bifurcation; mild (to moderate) atheromatous lesions in R middle CCA and L CCA bifurcation; mild atheromatous lesion in L distal CCA.
    • Elevated flow velocities in bilateral MCAs (PS/ED: R = 234/80, L= 182/55 cm/s), suggesting bilateral MCA stenosis; relatively reduced flow in R cervical VA as compared to L VA.
    • Normal extracranial carotid, L vertebral, and intracranial vertebral, basilar arterial flows.
    • Normal bilateral ophthalmic arterial flows
  • 2022-06-02 SONO - abdomen

    • Right renal cyst (0.85x1.12cm).
  • ……

  • ……

  • 2017-05-26 Surgical pathology Level VI

    • PATHOLOGIC DIAGNOSIS
      • Breast, left, modified radical mastectomy —- Invasive carcinoma of no special type, grade 3
      • Resection margins, ditto — Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Skin, ditto — Tumor invasion
      • Nipple, ditto — Tumor invasion
      • Lymph nodes, left axillary, dissection — Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
      • AJCC Pathologic Stage — pT4N1Mx, stage IIIB at least
    • MACROSCOPIC EXAMINATION
      • Breast: 18 x 12 x 3 cm
      • Skin: 15.5 x 7 cm
      • Nipple: 1.8 x 1.8 x 0.7 cm
      • Tumor: difficult to assess grossly. Only mild fibrosis of skin and few foci of fibrous nodules found. Microscopically, multiple foci of tumor measures up to 2.3 x 2 cm is noted.
      • Resection Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Lymph node: left axillary LNs
      • Representative sections as follows: A1: nipple, A2-A6: tumor; B1-B6: LNs.
    • MICROSCOPIC EXAMINATION (FOR INVASIVE CARCINOMA)
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: Multiple foci, up to 2.3 x 2 cm
      • Histologic grade (Nottingham histologic score): Grade III (score 8)
        • [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 2]
      • Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Nodal status: Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
      • Treatment Effect: N/A
      • Immunohistochemical study of CK highlights tumor is very close to base margin
  • 2017-05-25 PET scan

    • Glucose hypermetabolism in the left breast, compatible with breast malignancy.
    • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild glucose hypermetabolism in the L3 spine. Degenerative spine disease may show this picture.
  • 2017-05-22 Gynecologic ultrasonography

    • Endometrial thickening
  • 2017-05-16 Surgical pathology Level IV

    • Breast, left, sono-guide biopsy — Invasive carcinoma of no special type
    • Immunohistochemical stains:
      • CK14: loss of myoepithelial cells
      • E-cadherin: positive for tumor cells
      • ER: 90%, intensity 2+
      • PR: 10%, intensity 3+
      • Her2/neu: negative; DAKO score 1+
      • P53: positive, 100%
      • Ki67: 60-70% activity
    • Microscopically, the sections show a picture of invasive carcinoma of no special type of the breast tissue characterized by pleomorphic tumor cells show linear or nested pattern, infiltrate in the desmoplastic stroma.
  • 2017-05-16 SONO - breast

    • CC/Indication:
      • Lt breast mass and CNB performed 2012-11-06, 2012-11-19 (CNB = Core Needle Biopsy)
      • DCIS was told. (Chat GPT: DCIS stands for ductal carcinoma in situ. It is a non-invasive form of breast cancer where abnormal cells are found in the lining of the breast ducts but have not spread beyond the ducts into surrounding breast tissue. Although DCIS is not an invasive cancer, it is considered a pre-cancerous condition and has the potential to develop into invasive breast cancer if left untreated. Treatment options for DCIS typically include surgery, radiation therapy, and hormonal therapy.)
    • Suggestion and Plan
      • Bilateral breast cysts and fibroadenomas.
      • Left breast 9’region irregular hypoechoic tumor with prominent vascularity, suggest biosy.
    • BIRADS4

[consultation]

  • 2022-10-17 Rehabilitation
    • Q
      • This 70 year-old women, she has right breast cancer with right simple mastectomy + SLNB on 2022/10/18. We need your help for rehabilitation after surgery, thank you!!
    • A
      • We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
      • Premorbid functional status
        • Walk ID, ADLs ID.
      • Physical examination
        • 2022/10/17 10:42 T/P/R: 36.0 / 61bpm / 18bpm BP:134/64mmHg
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Bilateral shoulders ROM: nearly full range of ative and passive ROM
      • Past hx: left forzen shoulder (improved)
      • Hand and arm circumference (R/L,cm):
        • Elbow joint above 5cm 25/27
        • Elbow joint below 5cm 22.5/24
      • Left arm lymph edema now:
        • ISL grade I, stage I
        • soft, intact skin, no fibrotic change in left arm
      • previous record:
        • 2021/09/15 rehab OPD
          • Skin test +
          • ISL stage: III: fibrotic changes over the forearm and arm
          • Other complications: Frozen shoulder at end-range
      • Imp
        • Rt breast ca ,cT2N0M0 stage 2A
        • OP: right simple mastectomy + SLNB on 2022/10/18.
        • Past hx:
          • Recurrent lt breast ca s/p MRM on 2017-05-26
          • adjuvant C/T with EC ->T since 2017-06-19
          • Lt upper limb lymphedema
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[MedRec]

  • 2022-11-23 SOAP General and Gastroenterological Surgery
    • The multidisciplinary cancer team meeting concluded on 2022-10-28. The treatment plan for the patient is as follows: TC chemotherapy every three weeks for a total of four cycles, followed by CDK4/6 inhibitor (self-paid), radiotherapy, and five years of hormone therapy.
  • 2022-11-08 SOAP Radiation Oncology
    • A:
      • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy (2004-05-25 ~ 2004-07-16).
      • Predominant ductal carcinoma in situ, intermediate grade, with focal microinvasive ductal carcinoma of the left breast, stage pStageIA, pT1aN0(0/2)(cMx); ER(weak positive, 30%), PR(weak positive, 30%), Her2/neu: (negative, 1+), s/p partial mastectomy, left axillar sentinel lymph node biopsy, radiotherapy in 2013/03, and status during hormone therapy (Tamoxifen) since 2012/12/10, with left breast recurrence, s/p MRM and ALND (2017-05-26), stage pT4N1(1/20)(cN0), stage IIIB, s/p chemotherapy and radiotherapy, and status during endocrine therapy.
      • Invasive carcinoma of no special type, of the right breast, ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0),AJCC Pathologic Anatomic Stage pT2N3a, cM0, stage IIIC; Prognostic Stage — Stage IIIB, s/p MRM (2022-10-18)
    • P: Radiotherapy is indicated for this patient with the following indicators: stage pT2N3a, cM0
      • Goal: curative
      • Treatment target and volume: right chest wall, axilla, to low SCF
      • Technique: IMRT
      • Preliminary planning dose: 5000cGy/25 fractions of the right chest wall, axilla, to low SCF
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her elder sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of chemotherapy. RTC: at the last cycle of chemotherapy.

[surgical operation]

  • 2022-10-18
    • Surgery: MRM        
      • ChatGPT: MRM stands for modified radical mastectomy, which is a surgical procedure to remove breast cancer. It involves the removal of the entire breast tissue, including the nipple, areola, and axillary lymph nodes. In addition, the lining over the chest muscles is also removed in this procedure. The goal of MRM is to remove the cancerous tissue and prevent the spread of cancer to nearby lymph nodes and tissues.
    • Finding
      • a 3x2x2 cm slight firm subareolar mass in rt breast
      • SLN 3/3(+)    
      • multiple axillary LNs up to 1.5 cm in size  
  • 2017-05-26
    • Diagnosis: left breast cancer
    • PCS code: 63007B: Radical mastectomy - unilateral
    • Finding
      • Three nodules up to 0.5 cmin size over lt breast
      • axillar LNs sl enlarged

[radiotherapy]

  • 2004-05-25 ~ 2004-07-16 - Past Hx (according to the Hua-Lien record): After admission, systemic work up was done and NPC cT1N0M0 was diagnosed.
    • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy. RT total dose was 7020 cGy.

[chemotherapy]

  • 2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)

  • 2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

Femara (letrozole) KFEMA01

  • 2017-12-04 ~ undergoing 2.5mg QD

Granocyte (lenograstim) CGRAN01

  • 2023-04-26 - 250ug 2 days (2023-04-21 IPD)
  • 2023-04-05 - 250ug 2 days (2023-03-31 IPD)
  • 2023-03-13 - 250ug 2 days (2023-03-13 OPD)

Foliromin (ferrous sodium citrate) KFOLIR01

  • 2023-01-18 IPD on and off

==========

2023-04-24

  • The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.

  • The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.

  • If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.

2023-04-03

  • On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.

  • The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.

  • The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.

    • 2023-03-31 HGB 7.7 g/dL
    • 2023-03-13 HGB 8.4 g/dL
    • 2023-03-10 HGB 8.3 g/dL
    • 2023-03-02 HGB 8.6 g/dL
    • 2023-02-09 HGB 8.6 g/dL
    • 2023-01-18 HGB 8.4 g/dL
    • 2023-01-11 HGB 8.3 g/dL
    • 2022-12-21 HGB 11.4 g/dL
    • 2022-12-07 HGB 11.5 g/dL
    • 2022-11-28 HGB 11.9 g/dL
    • 2022-10-17 HGB 11.6 g/dL
    • 2022-06-08 HGB 12.6 g/dL
    • 2022-02-24 HGB 12.6 g/dL
    • 2021-04-29 HGB 12.7 g/dL
    • 2023-03-31 PLT 130 x10^3/uL
    • 2023-03-13 PLT 139 x10^3/uL
    • 2023-03-10 PLT 156 x10^3/uL
    • 2023-03-02 PLT 123 x10^3/uL
    • 2023-02-09 PLT 175 x10^3/uL
    • 2023-01-18 PLT 233 x10^3/uL
    • 2023-01-11 PLT 154 x10^3/uL
    • 2022-12-21 PLT 249 x10^3/uL
    • 2022-12-07 PLT 127 x10^3/uL
    • 2022-11-28 PLT 228 x10^3/uL
    • 2022-10-17 PLT 191 x10^3/uL
    • 2022-06-08 PLT 227 x10^3/uL
    • 2022-02-24 PLT 262 x10^3/uL
    • 2021-04-29 PLT 248 x10^3/uL
  • When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.

700835257

230421

[diagnosis] - 2023-03-22 admissiion note

  • Malignant neoplasm of unspecified site of right female breast
  • Unspecified lump in breast

[past history]

  • The patient had no systemic diseases

  • History of operation: NIL

  • Regular medications or herb: no

  • G2P2

  • menarche : 16y/o

  • menopause: 51y/o

  • Hormone therapy: (-)

  • Family history of breast cancar: NIL                        

[allergy]

  • NKDA         

[family history]

  • Her mother has type II diabetes mellitus and liver cirrhosis, father has pancreatic cancer.

[exam findings]

  • 2023-03-24 CT - chest
    • Indication: Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
    • Imp: s/p op. over right breast. Suggest follow up.
  • 2022-12-19 ECG
    • Right bundle branch block
  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 66
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; trivial TR.
  • 2022-11-18 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, right, partial mastectomy — Invasive lobular carcinoma
      • Resection margin: free
      • Lymph node, right, axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/3)
      • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IA, pT1cN0(sn)(if cM0) Prognostic stage: IA
    • Gross Description
      • Procedure: partial mastectomy
      • Lymph node sampling (if lymph nodes are present in the specimen): Sentinel lymph node(s)
      • Specimen laterality: Right
      • Breast: Size: 5.7 x 5.5 x 2.0 cm
      • Skin: Size: 2.8 x 0.5 cm.
      • Nipple: Not Included
      • Tumor: Size: 1.1 x 1.0 x 1.0 cm.
      • Resection Margin: Free, 0.2 cm from the deep margin
      • Sections are taken and labeled as: FsA: deep margin; FsB1-2: sentinel lymph nodes (FsB1: a bisected lymph node), for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: skin; X2: breast, non-tumor; X3-5: tumor.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive lobular carcinoma; The immunohistochemical stain of E-cadherin is negative.
        • Size of invasive carcinoma (mm): 11 x 10 x 10
        • Histologic grade (Nottingham histologic score): grade II (score 6)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 2
          • Mitotic count: score 1
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: not received
      • For Ductal Carcinoma In Situ: absent
      • Margins: Negative, Closest margin (2 mm from deep margin)
      • Nodal status: Negative, sentinel
        • No. examined: 3
        • No. macrometastases (>2 mm): 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: patient not received
      • Lymphovascular invasion: absent.
      • Perineural invasion: present
      • Immunohistochemical Study: S2022-16430
  • 2022-11-17 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2022-11-16 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-10-14 Bone Scan
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the mandible, middle C-spine, L4, bilateral shoulders, hips, knees and feet in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the middle C-spine and L4 spine. Degenerative change may show this picture.
      • Increased activity in the mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2022-10-14 CT - chest
    • Right breast cancer with non-specific lymph nodes are found at bilatral axillary region is found.
  • 2022-09-27 Patho - breast biopsy
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right 10.5/7 area, core needle biopsy — Invasive lobular carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of two strips of breast tissue measuring up to 0.8 x 0.1 x 0.1 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in one cassette.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show a picture of invasive lobular carcinoma characterized by dyscohesive tumor cells arranged in linear or cord pattern with desmoplasia. Immunohistochemistry shows CK5/6 and P63: loss of myoepithelial cell, E-cadherin(-), ER(>90%, intensity 2~3+), PR(>90%, intensity 1~2+), Her2/neu(-, Dako score 1+) and Ki-67: 5-10% for tumor.
  • 2022-09-27 SONO - breast
    • Treatment: core needle biopsy
    • Suggestion and Plan: Right breast tumor, suggest biopsy.
    • BI-RADS: Category 4c: suspicious abnormality-biopsy should be considered.
  • 2020-10-22 Gynecologic ultrasonography
    • RT adnexae: free I - EM:4.7mm

[consultation]

  • 2022-11-16 Rehabilitation
    • A
      • Imp
        • Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
      • OP: right partial mastectomy and SLND on 2022/11/17.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
          • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2022-11-17
    • Surgery
      • partial mastectomy and SLNB        
    • Finding
      • right 10/7 tumor, about 1cm in diameter
      • SLNB: negative of malignancy, 0/3

[chemotherapy]

  • 2023-04-20 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-22 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-27 - epirubicin 70mg/m2 100mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W) Epicin (decrease dosage from 90mg/m2 to 70mg/m2 due to WBC:3580, seg:37.6, ANC:1346)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-07 - epirubicin 90mg/m2 140mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-11 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)

  • CE (Epirubicin or Lipodox) F (Lipodox is not strongly recommended in the adjuvant setting)
    • Cyclophosphamide 500 mg/m2 IV Days 1
    • Epirubicin 90 mg/m2 IV Day 1 or Lipodox 30 mg/m2 IV Day 1
    • 5-fluorouracil 500 mg/m2 IV Days 1
    • _ References
      • Citrom, ML, et al.J Clin Oncol 21:1431-, 2003.1439
      • Martin M, et al. J Natl Cancer Inst 2008; 100:805-814.
      • O’brien, et al. Annals of oncology, 15(3). 440-449.
      • Rau KM, et al. BMC Cancer, 2015; 15: 423

==========

2023-04-21

  • Except for a slightly elevated ALT 52U/L, all other labs were normal on 2023-04-20. No problem with the active prescription.

2023-03-23

  • After the episode of neutropenia on 2023-02-27, the decision to reduce the dose of epirubicin in the CEF regimen was made. Subsequently, no further episodes of neutropenia were observed, even when the dose was increased to the standard recommended level.

700392038

230419

{not completed}

[diagnosis] - 2023-04-21 discharge note

  • Right lower lobe lung cancer, adenocarcinoma, T4N3M1c, stage IVB, with brain and lung to lung metastases s/p Target therapy with Afatinib from 2021/09/08~  
  • Secondary malignant neoplasm of brain
  • Chronic obstructive pulmonary disease, unspecified
  • Type 2 diabetes mellitus without complications
  • Diarrhea, unspecified

[exam findings]

  • 2023-04-10 CXR
    • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
    • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, sternum, some ribs, sacrum, left S-I joint and possible left sternoclavicular junction.
    • IMPRESSION: In comparison with the previous study on 2022/08/08, more new bone lesions are noted. The scintigraphic findings suggest multiple bone metastases.
  • 2023-03-21 CXR
    • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
    • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
  • 2023-02-08 EGFR mutation
    • Cell block No: S2023-01756
    • Result: Two mutations were detected at exon 20 (T790M) and exon 21 (L858R) of EGFR gene in this specimen.
  • 2023-02-06 CXR
    • A poorly defined large tumor with reticular opacities over Rt lower lobe
    • Enlargement of Rt hilum due to lymphadenopathy
    • Thoracic aortic calcified atheriosclerotic plaque
  • 2023-02-03 Patho - bronchus biopsy
    • Lung, RLL, bronchioscopic biopsy — adenocarcinoma, poorly differentiated
    • Sections show bronchial mucosa with infiltration of large pleomorphic solid tumor cells and acinar galndular cells.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), CD56(-), and p40(-). The results are supportive for the diagnosis.
  • 2023-02-01 CT - chest
    • Indication: Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis
    • Comparison was made with previous CT dated on 2022/08/03
      • Lungs: interval significant increase in size of RLL tumor with newly developed extensive interlobular septal thickening and peribronchoscular bundle thickeninng and new RML nodule as compared with CT on 2022/8/3. the tumor involves Rt inferior pulmonary artery and hilum.
      • Mediastinum and hila: enlarged LN in Rt hilum.
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura:small Rt effusion with parietal thickening.
      • Chest wall: metastatic LAP at Lt supraclavilar fossa
      • Visible abdominal contents: several small hepatic cysts and a Lt renal cyst 28mm
        • unremarkable of the adrenal glands, spleen, pancreas, adrenal glands
      • Visualized bones: no lytic or blastic lesion.
        • axial brain images: no evidence of brain metastasis based on noncontrast images. diffuse cerebral atrophy.
    • Impression:
      • RLL tumor, T4N3, in progression as compared with previous CT on 2022/08/03
  • 2023-01-30 ECG
    • Sinus tachycardia
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-08-08 Tc-99m MDP bone scan
    • A hot area at the L4-5 spines, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in both rib cages, some C- and L-spine, bilateral shoulders, and S-I joints.
  • 2022-08-03 CT - chest
    • RLL tumor, inccrease in size of the tumor T4 as compared with previous CT on 2022/03/02. no mediastinal LAP.
  • 2022-03-02 CT - chest
    • RLL tumor, slightly decrease in size of the tumor as compared with previous CT on 2021/11/24. no mediastinal LAP.
  • 2021-11-24 MRI - brain
    • Findings
      • Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
      • Only two small dark noudles were seen in right cerebellum and left anterior temporal lobe.
      • Poor or equivocal abnormal enhancement after contrast administration of those two nodules seen.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp: Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
  • 2021-11-24 CT - chest
    • RLL tumor, significant decrease in size of the tumor (21 mm on this exam) as compared with previous CT on 2021/08/10
  • 2021-08-31 Patho - bronchus biopsy
    • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.

[lab data]

2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected

[MedRec]

  • 2021-09-23 SOAP Chest Medicine
    • S
      • just discharged on 20210917 due to hemoptysis
      • EGFR mutation: L858R (+), exon 19 (-), ALK(-)
    • O
      • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date: 20210914
      • Dr Huang JunYao: check EGFR mutation status, apply TKIs for this case if indicated
      • Conclusion: palliation C/T, RT, best supportive care, EGFR TKIs if definite mutation
  • 2021-09-08 SOAP Chest Medicine
    • S
      • admission on 20210916 for Cyramza 600mg
      • A case of Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis, ECOG 1,
        • T4: RLL mass with RLL, RML
        • N3: bilateral mediastinal LAPs
        • M1c: multiple brain metasatsis
      • EGFR mutation: L858R (), exon 19 (), ALK(),
      • PD-L1:
      • Right hilum tumor, nature?
  • 2021-08-30 POMR Chest Medicine
    • Discharge Diagnosis
      • Chronic obstructive pulmonary disease, unspecified
      • Right hilum tumor, nature?
      • Right lower lung mass.
    • CC: Cough intermittent with hemoptysis for months
    • Present Illness
      • He suffered from hemoptysis to Zhongxiao Hospital for help in early August, Chest CT on 2021/08/10 showed RLL carcinoma with lung to lung metastasts and mediastinal LAP is considered first. Multiple small hypodense nodules in liver. Brain MRI on 2021/08/19 showed Multiple brain metastatic tumors should be considered. Whole body bone scan on 2021/08/20 showed likely DJD or certain entity in the L4.
  • 2021-08-23 SOAP Chest Medicine
    • S
      • Right hilum tumor, nature?
      • cough intermittent without scanty sputum for months, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
      • Past history: Allergic rhinitis, asthma
      • Family history of asthma
      • Smoking(-)
      • Allergic history(-)
      • Traveling history(-)
    • O
      • BP:120/70, HR:70
      • Throat: hyperemia
      • Tonsil: enlargement
      • Neck LAP(-)
      • Breathing sound: course(+), wheezing(+), crackle(+), decreased(+)
      • HS: RHB
      • Abdomen: soft and flat
      • Pitting edema(-)
  • 2021-05-19 SOAP Dermatology
    • S
      • Multiple painful erythematous papule-nodules on face, trunk and 4 limbs
      • Multiple erythematous scars and keloids on face for months, progressive enlarged recently. Itching(+), keloid(+)
    • O
      • Imp: acne on face and trunk for months, multiple pustule (+), inflammation(+), painful(+)
      • NSAID for pain release
    • Plan
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Diagnosis
      • L70.2 Acne varioliformis
      • L73.0 Acne keloid
    • Prescription
      • doxycycline 100mg/cap 1# BID PO 7 days
      • fusidic acid 1 tube BID EXT 7 days
      • Shincort (triamcinolone acetonide) 50mg ST IS (intrasynovial)

[medication]

  • 2023-03-07 ~ undergoing - Giotrif (afatinib 30mg) tab 1# QDAC
  • 2021-09-08 ~ 2022-10-05 - Giotrif (afatinib 30mg) tab 1# QDAC

700181400

230418

[diagnosis] - 2023-04-13 admission note

  • Rectosigmoid colon cancer with lymph node metastases s/p da Vinci robotic assisted radical low anterior resection on 2023/03/17, pT4aN2aM0, pStage IIIC
  • Insomnia, unspecified

[present illness] - 2023-04-13 admission note

  • This 45 year old woman suffered from diarrhea and loose stool passage since 2022/12. She also developed nausea notede, epigastric dull pain, fullness belching, acid regurgitation. Also bloody stool passage was noted on 2023/02/20 evening. Stool was collected and shoed occult blood 3+.
  • Colonoscopy was performed on 2023/03/02 and found one tumor occupied almost intralumenal circumference of colon at 15 cm from anal verge, pathology reported adenocarcinoma. Pelvis MRI on 2023/03/14 showed: 1. Rectosigmoid colon cancer about 3.5cm in length with regional lymphadenopathy about 3 in number. 2. A prominent soft tissue mass at left inguinal canal. 3. Small uterine myoma. 4. A nabothian cyst about 0.7cm. T3N1bMX. Due to above reasons, she was admitted for colon cancer staging. She received da Vinci robotic assisted LAR on 2023/03/17 and pathology showed adenocarcinoma, moderately to poorly-differentiated with lymph node metastatic (6/22), pStage IIIC, pT4aN2aMX, immunohistochemistry (IHC) Testing for Mismatch Repair (MMR) Proteins, no loss of nuclear expression of MMR proteins: low probability of microsatellite instability-high (MSI-H). Now, she was admitted to ward for Port-A catheter insertion and chemotherapy with FOLFOX(C1D1).
    • ChatGPT:
      • The term “no loss of MMR protein” refers to the absence of any detectable decrease or loss in the expression or function of proteins involved in the DNA mismatch repair (MMR) system. The MMR system is a crucial mechanism in cells that helps maintain genomic stability by correcting errors that may occur during DNA replication.
      • The primary MMR proteins include:
        • MLH1 (MutL homolog 1)
        • MSH2 (MutS homolog 2)
        • MSH6 (MutS homolog 6)
        • PMS2 (postmeiotic segregation increased 2)
      • Loss or dysfunction of any of these MMR proteins can lead to a condition called microsatellite instability (MSI), which is characterized by a higher rate of mutations in the DNA. MSI is associated with certain types of cancer, such as colorectal cancer and endometrial cancer, particularly in the context of Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer or HNPCC).
      • When there is “no loss of MMR protein,” it means that the MMR system is functioning properly in the cells, and the risk of developing cancers due to microsatellite instability is reduced. However, it is important to note that the presence of functional MMR proteins does not guarantee the complete absence of cancer risk, as there may be other factors or mechanisms contributing to cancer development.

[past history]

  • DM(-), HTN(-)
  • Uterine myoma uteri status post myomectomy on 2018/08/09
  • GERD, LA grade A history of Hp infection before noted at LMD.
  • da Vinci robotic assisted radical low anterior resection on 2023/03/17

[allergy]

  • NKDA

[family history]

1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.

[lab data]

2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO

[chemotherapy]

[assessment]

  • Lab data for hepatitis B virus is provided. It is recommended to initiate treatment with either Baraclude (entecavir) or Vemlidy (tenofovir alafenamide) before starting chemotherapy to minimize the risk of reactivation.
    • 2023-04-17 Anti-HBc Reactive
    • 2023-04-17 Anti-HBc-Value 4.11 S/CO
    • 2023-04-17 Anti-HBs 774.10 mIU/mL
    • 2023-04-17 HBsAg Nonreactive
    • 2023-04-17 HBsAg (Value) 0.40 S/CO

700534651

230418

[exam findings]

  • 2023-04-06 SONO - chest
    • Special Procedure:
      • echo-assisted
      • Pleural tapping 16 #-needle Left side 550 ml bloody
    • Echo diagnosis:
      • pleural effusion
        • Chest echography was performed first. The suitable intercostal space was selected and located.
        • Catheter was inserted with negative pressure smoothly.
        • Left side pleural effusion was drawn smoothly.
        • Watch out BP after tapping.
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block),
      • biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-04-03 CT - chest
    • Findings
      • moderate Lt pleural effusion.
      • Lungs: a subsegmental consolidation at LLL-laterobasal segment.
        • mosaic attenuation changes in Rt lung, LUL, and aerated Lt lower lobe. there is subpleural reticulation and ground-glass opacity at both lower lobes too.
      • Mediastinum and hila: a 15mm calcification in posterior Rt hilum.
        • extensive mild calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
      • Heart: normal in size of cardiac chambers. mild calcified aortic valves.
      • Chest wall and visible lower neck: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or suspected tumor.
      • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
      • extensive 3V-CAD.
  • 2023-03-29 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • small Lt pleural effusion
    • volume reduce over Lt lower lung zone
    • a short linear high density over Rt infrahilar shadow, foreign body?
    • S/P posterolateral bony fusion at L-spine
  • 2020-06-29 Right knee standing
    • Osteoarthritis change of right knee with joint space narrowing and marginal spur formation. Loose bodies in the right knee joint.
  • 2020-06-29 KUB and Lumbar spine lateral:
    • Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Grade 1 degenerative spondylolisthesis at L4-5 level. Degenerative change of the spine with marginal spur formation. Osteopenia of visible bones. L5-S1 disc space narrowing.

[SOAP]

  • 2023-04-06 Chest Medicine
    • past history: alzheimzer disease under licodin, HTN
    • chest tapping for exam.
  • 2023-04-06 Hemato-Oncology
    • S
      • This 77 year old woman with dementia, HTN and insomnia came to our OPD due to hemptosis for 10+ days, shortness of breath on excertion, body weight loss (4-5kg in 10 months)
      • Smoking history for 20+ years, quit for 20+ years
      • Lives in Nanshijiao, has five children (lives with the eldest daughter, one passed away from throat cancer, one lives in Tainan, one was given to another family to raise, and the youngest daughter lives in Nangang).
    • O
      • 2023/04/03 CT: Lung/Mediastinum/Pleura
        • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or r/o tumor.
        • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
        • extensive 3V-CAD.
    • A
      • Arrange admisson for CT-guided biopsy
      • Suspected lung cancer
      • Suggestion: admitted for further evaluation
    • P
      • Chest contrast CT
      • CT gudide biopsy
      • check tumor marker
  • 2023-04-03 Chest Medicine
    • chest sono on 2023/04/06 PM0230
    • hold Licodin (ticlopidine) since 2023/04/04
    • refer to oncologist for suspected Left lower lung pleural based tumor
  • 2023-03-29 Chest Medicine
    • S: hemoptysis (blood in phlegm) for 10 days, mld short of breath
      • consciousness: clear
      • breath sound: clear
      • abdomen: soft, no tenderness
      • extremities: freely movable; no pitting edema
      • smoking:quit for 20 years
      • past history: alzheimzer disease, HTN
    • O: CXR: bilateral increased infiltrate
    • P:
      • suggest ER for admission, but the patient and family hesitate (unable to be hospitalized these days)
      • suggest if hemoptysis progressed -> ER admission
      • check lab
      • arrange chest CT on 2023/04/03
      • sputum TB x3
    • Diagnosis
      • R04.2 Hemoptysis
      • J15.9 Unspecified bacterial pneumonia
    • Medication
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) cap 1# TID 5 days
      • Cravit (levofloxacin 500mg) tab 1.5# QDAC 5 days
      • Transamin (tranexamic acid 250mg) cap 1# BID 5 days
  • 2023-02-22 Oral and Maxillofacial Surgery
    • S
      • current medication
        • antihypertensive drug
        • peripheral vasodilators for dementia
    • O
      • Panoramic findings:
        • Missing: nil
        • Impaction: nil
        • Crown and Bridge: 11,15,16,25,26,34-35X,43-44-45XX
        • Caries: nil
        • Periodontal condition: chronic periodontitis
      • vascular spot on the lower alveolar mucosa and tongue was noticed, might be drug-related
  • 2023-02-16 Family Medicine
    • CC
      • HTN loss f/u
      • headache
      • mild petechiae over lips and gum -> ginko related?
    • Past history HTN, dementia
    • Allergy history (-)
    • previous medication: Ginkgo, Stilnox, Xyzal

[assessment]

  • The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.

  • If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).

700555767

230418

[chief complaint] - 2023-04-17 admission note

  • Vertigo since 2023/01/07, progress for 2 weeks

[present illness] - 2023-04-17 admission note

The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.

[past history]

  • hypertension under CV OPD follow up
  • constipation

[allergy]

  • NKDA

[family history]

  • No cancer, CVA, CAD or DM in her family

[exam findings]

  • 2023-04-17 CT - brain
    • CC
      • bedridden for 3 months after falling down
      • dizziness, vertigo, nausea, no tinnitus
      • right hip pain
    • phx: HTN, dyslipidemia, HBV carrier
      • NKDA
      • pregnancy: denied
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
      • Sella and pituitary are normal, parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • Left parietal skull osteolytic destruction, nature?
    • Imp:
      • Mild cortical brain atrophy.
      • Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation?
      • Chronic left mastoiditis.
  • 2023-04-17 Hip joints Rt
    • Permeative osteolysis over Rt acetabulum and superior pubic ramus and body, metastatic lesion d/d diffuse osteoporosis
  • 2023-04-17 CXR
    • marginal spurs of multiple vertebral bodies of T-spine due to spondylosis.

[SOAP]

  • 2023-04-17 Emergency
    • Diagnosis
      • N63 - Unspecified lump in breast
      • M89.59 - Osteolysis, multiple sites
      • R42 - Dizziness and giddiness
      • Z74.01 - Bed confinement status
  • 2021-08-03 Cardiology
    • Objective
      • 2021/08 123/75; 70;
    • Medication
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
  • 2019-11-21 Cardiology
    • Objective
      • 2019/11 128/80; 65
    • Medication
      • Concor (bisoprolol 5mg) 0.5# QD <- 1# QD
  • 2019-08-02 Cardiology
    • Assessment
      • Essential hypertention, unspecified [I10]
      • Obesity, unspecified [E66.9]
      • Hepatitis B carrier [Z22.51]
      • Gout, unspecified [M10.9]
    • Medication
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Natrilix SR (indapamide 1.5mg) 1# QD

[assessment]

  • An unspecified breast lump and multiple-site osteolysis are under investigation.
  • The patient’s underlying hypertension and obesity are well controlled with Olmetec (olmesartan), Norvasc (amlodipine) and Concor (bisoprolol) prescribed by our cardiologist without any medication reconciliation issues.
  • To date, there is no evidence of hyperuricemia (although this diagnosis remains in the cardiology OPD records). On 2023-04-17, the patient’s serum uric acid level was 5.4 mg/dL.
  • The most recent data for total cholesterol, triglycerides, LDL, and HbA1c were obtained on 2022-09-20 and may need to be updated.

700891439

230418

[diagnosis] - 2023-04-12 admission note

  • Malignant neoplasm of rectum
  • Malignant neoplasm of bladder, unspecified
  • Iron deficiency anemia, unspecified
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection)

[past history]

  • Squamous cell cacinoma of the Lt buccal region, stage T4aN0M0 (IVA), s/p wide excision, segmental osteotomy, and supraomohyoid neck dissection, radiotherapy, and chemotherapy in 2008
  • Small bowel ileus post enterolysis with bowel decompression in 2018
  • Ileus s/p Explosive laparotomy in 2018
  • Adenocarcinoma of rectum, pT2N2a(cM0), stage IIIB, s/p EXP LAP with AR and enterolysis, and s/p CCRT
  • Invasive urothelial carcinoma s/p transurethral resection of bladder tumor on 2021/05/28
  • Adhesion ileus s/p operation on 2018/04/20

[family history]

  • elder brother: lung cancer
  • father: liver disease
  • No members of the family with colon cancer.

[lab data]

  • 2021-07-14 All-RAS not detected
  • 2021-07-14 BRAF not detected
  • 2021-07-07 PD-L1(22C3) CPS>=1 and <10
  • 2021-07-07 PD-L1(28-8) TC>=1% and <5%

[exam findings]

  • 2023-04-14 Patho - gingival/oral mucosa biopsy
    • Mass, right buccal mucosa, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by tumor nests with enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma with keratin material.
    • Immunohistochemical stains show CK(+); P63(+) and P16(-) for tumor.
  • 2023-04-13 Nasopharyngoscopy
    • Finding: granular tumor over right buccal, retromolar, gingivobuccal
    • Conclusion: right buccal ca
  • 2023-03-28 CT - neck
    • Indication: right facial tumor bleeding noted on 1AM. he had similar episode 2 weeks ago. The mass was noted for 2-3 months, which is growing with bleeding and pus formation.
    • Past history: double ca (colon ca and bladder ca) folfox 6 R/T, Bladder cT2N0M0 stage II UC with squamous change
    • Protocols: Axial scans with 2 mm slice thickness with multiplanar image reformation using Aquilion Prime CT.
    • Neck CT without/with contrast enhancement shows:
      • large enhancing mass at right buccal region (maximal diameter about 8cm), with direct invasion to right mandibular bone and right masticator space muscles, including masseter and temporalis muscles and probably also pterygoid muscles. Advanced right buccal cancer is compatible. T4b disease is considered.
      • multiple enlarged lymphadenopathy at right level Ib, II, Va. Possible extranodal invasion cannot be well evaluated in CT. N2b disease is favored.
      • bilateral symmetric pharyngeal mucosa.
      • chronic right maxillary sinusitis with complete sinus opacity and sinus bone thickening.
    • Impression: Advanced right buccal cancer, image staging favor AJCC T4bN2b, stage IVB.
  • 2022-12-24 CT - abdomen
    • s/p LAR. No evidence of recurrent/residual tumor in the study.
  • 2022-07-30 CT - abdomen
    • S/P colon and bladder operation. No evidence of tumor recurrence.
  • 2022-02-15 CT - abdomen
    • Post-op at the colon. Suggest follow up.
    • Liver cysts.
    • Left lower lung nodule 0.4cm, stationary, suggest follow up.
  • 2021-06-24 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Rectum, EXP LAP with low anterior resection — Adenocarcinoma, moderately differentiated
      • Resection margins, EXP LAP low anterior resection — Free
      • Lymph nodes, mesocolorectal, dissection — Metastatic adenocarcinoma (6/22)
      • Pathology stage: pT3N2a(cM0); Stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: EXP LAP low anterior resection
      • Specimen site: Rectum + sigmoid colon
      • Specimen size: 20.5 cm in length
      • Tumor size: 5.8 x 4.5 cm
      • Tumor location: 4.0 cm away from the distal resection margin
      • Depth of invasion grossly: Perirectal soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A5=tumor, A6-A10= regional LNs, B= proximal end, C= distal end.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Perirectal soft tissue
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Intermediate
      • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin
      • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (6/22) (No. Positive / No. Total)
      • Extranodal involvement: Present
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT3 (Tumor invades pericolorectal tissues)
        • Regional Lymph Nodes (pN): pN2a (4 to 6 regional lymph nodes are positive)
        • Distant Metastasis (pM): cM0
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • Tumor regression grading S/P CCRT: N/A
      • IHC (S2021-7997): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2021-06-23 PD-L1 (SP142)
    • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma (S2021-08015)
      • PD-L1 Expression: <5% IC
      • Scores – Immune cells (IC): 2%; Tumor cells (TC): 0%
  • 2021-06-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 47.8) / 126 = 62.06%
      • M-mode (Teichholz) = 62.1
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mitral valve prolapse (posterior leaflet) with trivial regurgitation
      • Trivial tricuspid regurgitation
      • Thick IVS and dilated aortic root
  • 2021-05-28 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Urianry bladder, “tumor”, near neck at 11-1 o’clock, TURBT — Invasive urothelial carcinoma with marked squamous differentiation, high-grade
      • Urinary bladder, “base”, TURBT — Involved by carcinoma
    • MICROSCOPIC EXAMINATION
      • Histologic type: Urothelial carcinoma, invasive, with marked squamous differentiation
      • Histologic grade: High-grade
      • Tumor configuration: Papillary and nodular
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
      • Specimen labeled “base”: Involved by carcinoma
  • 2021-05-27 Patho - colon biopsy
    • Intestine, large, rectum, near R-S junction, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • IHC stain — EGFR(+), PMS2(+), MSH2(+), MSH6(+), MLH1(+)
  • 2021-05-27 Colonoscopy
    • Suspected colon cancer, rectum near R-S junction, 15cm from anal verge, s/p biopsy
    • Mixed hemorrhoid
  • 2021-05-24 CT - abdomen
    • History and indication: fever, L’t abd pain, cause?
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with regional LAP.
      • A tumor (3.3cm) in urinary bladder r/o malignancy.
      • A soft tissue nodule (2.5x5.8cm) in presacral region r/o GIST.
      • Small liver cysts (3-6mm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[surgical operation]

  • 2021-06-23
    • Surgery
      • EXP LAP with AR and enterolysis     
    • Finding
      • Rectal tumora invasion to bladder, Adenocarcinoma of rectum, stage T2N2aM0, stage IIIB
      • Anastomosis by CDH 33#
      • Previous surgery, severe adhesion  
  • 2021-05-28
    • Surgery
      • Transurethral resection of bladder tumor
    • Finding
      • urethral trauma during urethral dilation
      • Bilateral U/O normal with clear efflux
      • A large round shape tumor with hypervascularity tumor beneath normal mucosa was noted at anterior wall or urinary bladder. The location is very near 11 o’clock bladder neck. Based on clinical finding, it is hard to tell whelther it came from urinary bladder or prostate
      • Risk evaluation:
        • Tumor size: >3cm
        • Multifocality: solitary
      • a wrinkle at left posterior wall, compatible with location of sigmoid colon with wall thickening

[chemotherapy]

  • 2022-01-24 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-10 - (FOLFOX Q2W)
  • 2021-12-27 - (FOLFOX Q2W)
  • 2021-12-13 - (FOLFOX Q2W)
  • 2021-11-29 - (FOLFOX Q2W)
  • 2021-11-15 - (FOLFOX Q2W)
  • 2021-10-25 - (FOLFOX Q2W)
  • 2021-10-11 - (FOLFOX Q2W)
  • 2021-09-27 - (FOLFOX Q2W)
  • 2021-09-13 - (FOLFOX Q2W)
  • 2021-08-30 - (FOLFOX Q2W)
  • 2021-08-02 - (FOLFOX Q2W)

700154637

230417

[past history] - 2023-04-13 admission note

  • s/p appendectomy at the age of 18
  • Brenner tumor and benign mucinous cystadenoma s/p left salpingo-oophorectomy on 2008-05-20 at our hospital
  • The recurrence of brenner tumor and benign mucinous cystadenoma s/p ATH and right oophorectomy on 2012-02 at CGMH
  • Brenner tumor and benign mucinous cystadenoma with pelvic seeding and partial intestinal obstruction, due to tumor involvement and adhesion s/p excision of pelvic tumor and enterolysis and segmental resection of ileum with anastomosis on 2014-01-20
  • Brenner tumor s/p chemotherapy x3 three years ago (from peripheral line)
  • Colon cancer s/p OP
  • GB stone
  • Hemmorhoids

OB/GYN history:

  • Menarche: 18 Y/O
  • Menopause: 52 y/O
  • G5P4AA1
  • No perimenopausal hormone therapy
  • No smoking
  • No family members had breast CA, endometrial CA, ovary CA and colon CA

[allergy]

  • Ulexin (cephalexin 500 mg/cap) local rash

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-14 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, middle and lower T-spines, L5-sacrum junction, bilateral shoulders, right sternoclavicular junction and bilateral elbows in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the middle and lower T-spines and L5-sacrum junction. Degenerative change is more likely.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in bilateral shoulders, right sternoclavicular junction and bilateral elbows, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2023-04-12 CXR
    • Patch density at RUL.
  • 2023-04-12 CT - abdomen
    • CC: abdominal pain, Lower abdominal dull pain for 3 months, progressed in 2 days. No diarrhea, no N/V, No fever, No dysuria
    • Past history:
      • Right ovarian cancer s/p TAH + BSO
      • Metastatic carcinoma in left pelvic cavity with sigmoid colon and left distal ureteral involvement, T4N0Mx s/p sigmoid colon resection
      • GB stones
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes, the largest one 3 cm in S2/3, that are c/w metastases.
      • Multiple gallstones are noted.
      • S/P hysterectomy
      • S/P LAR with autosuture retention over the sigmoid colon.
      • There are two small soft tissue nodules 5 mm in RML of the lung.
        • Please correlate with chest CT to R/O metastases or inflammatory process.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Multiple metastases on both hepatic lobes.
      • Two small soft tissue nodules 5 mm in RML of the lung, nature?
        • Please correlate with chest CT.
  • 2023-04-12 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2023-03-21 KUB
    • Rim calcification in RUQ.
    • Mild lumbar spondylosis.
  • 2023-03-21 Renal ultrasound
    • Grossly normal, bilateral kidneys
  • 2020-06-19 Pap Smear
    • Atrophy with inflammation
  • 2020-03-10 KUB
    • Degenerative change of the lumbar spine
  • 2020-03-10 CT - abdomen
    • Indication: acute onset diffused abdominal pain, with radiation to the back, nausea.
    • PMH: ovarian and uterus cancer s/p OP
    • Protocols: Axial scans with 5 mm slice thickness with multiplanar image reformation using 64-slice MDCT.
    • Abdomen & Pelvis CT without/with contrast enhancement shows:
      • postoperative change with suture material in the pelvic cavity.
      • clustered dilated small bowel loops (mainly ileum) in the pelvic cavity, with abrupt tapering of lumen at transition zone. Adhesion ileus is first considered.
      • colon is not dilated.
      • no ascites; no intraperitoneal free air.
      • tiny simple hepatic cysts in left hepatic lobe.
      • no definite focal lesion in the spleen, pancreas, bilateral kidneys and adrenal glands.
      • multiple gallbladder stones.
    • Impression:
      • Postoperative change in the pelvic cavity. Focal small bowel ileus in the pelvis, favor adhesion ileus.
      • Multiple gallbladder stones.
      • Tiny simple hepatic cysts, left lobe.
  • 2018-11-30 CT - abdomen
    • Chief Complaints: abd pain, upper abodmen, Nausea (+), vomiting (-), Diarrhea (-) Radiation to back (-) constipatin (-)
      • Past History: Nil
      • Surgical history: Hysterectomy and oophorectomy
      • Drug allergy: Ulex
      • Stomach ache sudden onset since 4 pm
    • Indication: R/O intestinal obstruction.
    • Without and with contrast Abdomen CT showed
      • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys
      • post-OP change in the rectosigmoid colon.
    • Impression: post-OP change in the rectosigmoid colon.
  • 2018-11-30 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Osteopenia of the bony structure is noted.
  • 2018-11-30 KUB
    • Osteopenia of the bony structure is noted.
  • 2018-03-06 Surgical pathology Level V
    • Clinical diagnosis: Malignant ovary neoplasm
    • Pathological diagnosis
      • Labeled as “pelvic mass”, excision — Adenocarcinoma.
        • IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036).
        • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
      • Labeled as “sigmoid colon”, resction — Free
      • Lymph node, epricolonic, sigmoid colon resection — Metastatic carcinoma (1/1) with extra-nodal extension.
    • MICROSCOPIC DESCRIPTION:
      • Sections of the pelvic tumor mass show adenocarcinoma with neoplastic glands lined by goblet cells and elongated nuclei.
        • IHC stains: CK7 (+), CK20 (focal +), the pattern the same as previos pattern (S2014-1036).
        • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
      • Section of the sigmoid colon show bland colonic mucosa, submucosa, muscular layer and serosa. One lymph node at the resection margin shows tumor metastasis with extra-nodal extension.
  • 2018-01-30 Sigmoid fiberscopy
    • external compression and scopy can not pass through since 10 cm from AV
  • 2018-01-30 Upper GI panendoscopy
    • Hiatal hernia with reflux esophagitis, Gr A  - Superficial gastritis, antrum and body
  • 2018-01-29 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Osteopenia of the bony structure is noted.
  • 2018-01-29 CT - abdomen
    • A multiloculated cystic lesion (4.9x8.8cm) at left pelvic cavity.
    • Gall stones (0.3-1.4cm). A hypodense nodule (0.3cm) at left hepatic lobe.
    • S/P colon operation.
    • Focal wall edema of small bowel at pelvic cavity.
  • 2016-03-15 SONO - OBS
    • L’t adnexal mass: 62x51mm (RI:0.17, RI:0.78)
  • 2016-03-15 CT
    • S/P hysterectomy.
    • R/O recurrence malignancy in left pelvic cavity with sigmoid colon and left distal ureteral involvement.
    • GB stones with GB fundus wall thickening.
  • 2015-04-22 CT
    • In favor of S-colon cancer (T4N0Mx) (The gold standard of evaluation of lymph node metastases and detailed tumor status is microscopic examination).
    • cStage: T4N0Mx.

[consultation]

  • 2023-04-17 Family Medicine
    • Q
      • This 79 year old woman patient is a case of right ovairan cancer s/p TAH + BSO with pelvic cavity, sigmoid, ureteral involvement s/p OP with liver metastases. Laparotomy on 2008/05/21. OP with TAH+BSO in 2012/02 at CGMH. Debulking with pelvic lymph node enlargement, suspect recurrent ovarian tumor and pelvic tumor, r/o recurrent ovarian cancer with invasion to sigmoid colon on 2018/03/05 and pathology showed Adenocarcinoma. IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036). Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-). Lymph node, epricolonic, sigmoid colon resection pathology showed metastatic carcinoma (1/1) with extra-nodal extension. Patient and family refuse further chemotherapy.
      • For pain control and hospice care, we need your further evaluation and management.

[surgical operation]

  • 2018-03-05 Debulking
  • 2012-02 (at CGMH) TAH + BSO
  • 2008-05-21 Laparotomy

[assessment]

  • This patient and her family refuse further chemotherapy, so family medicine is consulted for combined hospice care and pain management.
  • Palliative and supportive care is provided. There is no problem with the active prescription.

700824633

230417

[exam findings]

  • 2023-02-22 CT - abdomen
    • History:
      • 20230117 CT: Ileocecal mass lesion causing small bowel obstruction. Please correlate with colonoscopy.
      • 20230118 S/P ileostomy for decompression.
      • 20230216 S/P right hemicolectomy: A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy.
    • Indication: R/O IAI (Intra-Abdominal Infection)
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformatted isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status cannot be determined without IV contrast.
    • Findings:
      • There is pneumoperitoneum that may be post-operative change.
        • The differential diagnosis includes hollow organ perforation.
      • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
      • S/P right hepatectomy
      • S/P cholecystectomy.
      • S/P Jackson-Pratt drainage tube insertion from right flank area and the tip located over subhepatic space.
      • Others
        • There is no hyper-or hypodense lesion in the liver, biliary system, pancreas, spleen & both kidneys.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • There is pneumoperitoneum that may be post-operative change. The differential diagnosis includes hollow organ perforation.
      • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
  • 2023-02-17 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, cecum, right hemicoloectomy — Mucinous adenocarcinoma, poorly differentiated
      • Margin, proximal and distal: Free
      • Omentum, right hemicoloectomy — Adenocarcinoma, seeding
      • Lymph node, regional, dissection — Meatastatic adenocarcinoma (2/17)
      • Ileostomy, closure — Confirmed
      • AJCC 8th edition pathology stage: pT4aN1bM1a; AJCC stage IVA
    • Gross Description:
      • Procedure: Right hemicolectomy
      • Tumor Site: Cecum
      • Tumor Size: 6.2x 4.2 cm
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as:1:bil cut-ends, A2:stomy, A3-5:tumor, A6-8:LNs, X1-3:tumor, X4:omentum, X5:LNs
    • Microscopic Description:
      • Histologic Type: Mucinous adenocarcinoma
      • Histologic Grade: G3 - Poorly differentiated
      • Tumor Extension
        • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
          • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Present
        • Specify number of deposits: Mesocolon
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: Positive (2/17)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT)
            • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
          • Regional Lymph Nodes (pN)
            • pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM)
            • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: Pending
      • Comment(s): None
      • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (98 - 27) / 98 = 72.45%
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Indeterminated LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR; trivial TR; mild PR.
  • 2023-02-15 Flow Volume Chart
    • normal ventilation
  • 2023-02-14 CXR
    • A calcification at LUQ.
  • 2023-01-17 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2021-03-24 Treadmill Exercise Electrocardiogram
    • The patient exercised according to the BRUCE for 06:16 min:s, achieving a work level of max METS: 7.3. The resting heart rate of 67 bpm rose to a maximal heart rate of 115 bpm. This value represents 77 % of the maximal, age-predicted heart rate. The resting blood pressure of 139/57 mmHg, rose to a maximum blood pressure of 216/70 mmHg. The exercise test was stopped due to Dizziness, Leg discomfort.
    • Conclusion: Inadequate exercise load
  • 2018-11-14 Myocardial perfusion SPECT with persanti
    • The Tl-201 stress myocardial perfusion scan was performed after sequentially injecting 38.1 mg of dipyridamole and 2.3 mCi of the radiotracer to the patient. The images after stress revealed mildly decreased radiotracer perfusion to the apical lateral wall of the left ventricle. The images at rest revealed further decline radiotracer perfusion to aforementioned hypoperfused area of the left ventricle. No dilatation of the left ventricle was noted.
    • IMPRESSION:
      • Probably normal variant or mild myocardial ischemia in the apical lateral wall of the left ventricle.
      • No post-stress dilatation of the left ventricle.
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78.2 - 25.6) / 78.2 = 67.26%
    • Report
      • AO(mm) = 32.8
      • LA(mm) = 36
      • IVS(mm) = 13.1
      • LVPW(mm) = 10.9
      • LVEDD(mm) = 41.9
      • LVESD(mm) = 26.4
      • LVEDV(ml) = 78.2
      • LVESV(ml) = 25.6
      • LV mass(gm) = 177.5
      • RVEDD(mm)(mid-cavity) =
      • TAPSE(mm) = 22.6
      • LVEF =
      • M-mode(Teichholz) = 67.3
      • 2D(M-Simpson) =
    • Diagnosis
      • Heart size: Normal
      • Thickening: IVS
      • Pericardial effusion: None
      • LV systolic function: Normal
      • RV systolic function: Normal
      • LV wall motion: Normal
      • Valve lesions:
        • MV prolapse: None
        • MS: None
        • MR: None
        • AS: None, Max.AV velocity = 1.3 m/s
        • AR: None
        • TR: Trivial, Max.pressure gradient = 22.8 mmHg
        • TS: None
        • PR: None
        • PS: None
      • Mitral E/A = 53.5 / 68.1 cm/s (E/A ratio= 0.79 )
      • Mitral E’/A’ = 6.9 / 12 cm/s (septal MA); E/E’ = 7.8
      • Intracardiac thrombus: None
      • Congenital lesion: None
    • Conclusion
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial tricuspid regurgitation
      • Mildly thicked IVS

[consultation]

  • 2023-01-17 Colorectal Surgery
    • Q
      • For small bowel illeus due to suspected cecum tumor obstruction
      • The 75 year old woman suffered from no stool and no gas release for 1 week and her abdomen became distended and gradually painful. She visited our ER today and KUB showed small bowel illeus, and CT was done that it was suspected a cecum tumor obstructed the bowel. As a result, we need your expertise to evaluate if she needed emergent operation, thanks!
    • A
      • O
        • CT:
          • Dilatation of small bowel and collapse of colon, r/o obstruction.
          • Wall thickening at ileocecal junction with perifocal fat stranding.
          • Several lymph nodes, at least 8, in right mesocolon.
          • Unremarkable chagne of the liver, spleen, pancreas, and kidneys.
          • No ascites or extraluminal free air.
          • No bony destructive lesion on these images.
        • No fever
        • Vital signs: stable
        • Abdomen: soft, no peritoneal signs or muscle guarding, mild tenderness and distended
      • A: R/O tumor of cecum with obstruction
      • P:
        • Diverting ileostomy for decompression first followed by staged right hemicolectomy 2-3 weeks later is recommeneded
        • The operation will be performed tomorrow on call
        • Please keep current treatment (NPO, NG, nutrition support, antibiotics, Albumin use, check tumor makers)
        • We’ll take over this patient tomorrow morning

[surgical operation]

  • 2023-02-16
    • Surgery
      • Exp. Lap with right hemicolectomy and closre of loop-ileostomy
    • Finding
      • A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy
      • Right hemicolectomy was carried out smoothly and anastomosis using endo-GIA for both ends and side-to-side hand-sewn sutures with 4/0 PDS+ silk.
      • Blood loss was about 30ml. A drain in right subhepatic region
  • 2023-01-18
    • Surgery: Loop-ileostomy    
    • Finding: Dilation of small bowel with wall edema and some ascites. Loop-ileostomy was created at RLQ abdomen. The whole procedure was smooth. 
  • 2017-11-20
    • Diagnosis: varicose vein
    • PCS code: 69014B
    • Finding: left varicose vein with posterior thigh varicose lake

[chemotherapy]

  • 2023-04-13 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4323mg NS 1000mL 46hr (FOLFOX Q2W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-27 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 617mg NS 250mL 2hr + fluorouracil 2800mg/m2 4320mg NS 1000mL 46hr (FOLFOX Q2W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[assessment]

  • The modified FOLFOX6 regimen was administered on 2023-03-27 and 2023-04-13, and severe diarrhea with 10 bowel movements each day occurred on 2023-03-28 and 2023-04-14.
  • Treatment should be withheld for grade 2 or worse diarrhea and restarted at a 20% lower dose of all agents after complete resolution. A dose reduction of oxaliplatin is recommended (to 75 mg/m2 for patients in the adjuvant setting and 65 mg/m2 for patients with advanced disease). Since the bolus FU is skipped in the regimen used, consideration may be given to reducing the infusional FU from 2800mg/m2 to 2400mg/m2 after recovery from grade 3 or 4 diarrhea in the previous cycle.
  • Severe diarrhea, mucositis, and myelosuppression following FU should lead to evaluation for DPD deficiency.
  • Loperamide is recommended as initial therapy for chemotherapy-related diarrhea (CRD). For mild to moderate (grade 1 or 2) uncomplicated CRD, an initial dose of 4 mg should be administered, followed by 2 mg every 4 hours or 2 mg after each loose stool (maximum daily dose of 16 mg). For severe (grade 3 or 4) diarrhea, or mild to moderate diarrhea complicated by moderate to severe abdominal cramping, grade 2 or worse nausea/vomiting, decreased performance status, fever, sepsis, neutropenia, frank bleeding, or dehydration, or mild to moderate uncomplicated diarrhea that persists after 24 hours of loperamide, high-dose loperamide (4 mg initially followed by 2 mg every 2 hours; maximum daily dose 16 mg) should be used. Loperamide was prescribed on 2023-03-30 when the patient was discharged after her first dose of FOLFOX.

700841910

230417

{not completed}

[exam findings]

  • 2023-04-16 Nasopharyngoscopy
    • Findings
      • smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold
    • Diagnosis/Conclusion
      • hypopharynx ca
  • 2023-03-02 Nasopharyngoscopy
    • Findings: 3/2 fiber = RT since 3/1 + CT (3/2 3 courses left), dyspnea, R false cord bulging
  • 2023-02-13 MRI - larynx
    • Indication
      • Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets), s/p incomplete CCRT (2022-09-21 ~ 10-20).
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows (comparison: 2022/08/19 MRI)
      • No evident abnormal enlarged lymph node in the visible neck. Regressed LNs seen on prior MR study.
      • Markely Regressed hypopharygeal tumor.
      • After IV contrast administration shows well or heterogenous enhancement in right hypopharynx and around the esophagus inlet (around NG tube, edema?).
      • Presence of soft tissue swelling over bil. neck, post R/T change likely.
      • No evident bony destructive lesion.
    • IMP: Markedly regressed neck LAPs. Markely regressed right hypopharyngeal tumor, likely with minimal residual tumor mass or edematous change, suggest follow up.
  • 2023-02-02 Nasopharyngoscopy
    • Hypo ca undergoing CCRT
    • NG+
  • 2023-01-30 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Bilateral renal cysts measuring 4.3cm is found at right side.
      • Enlarged prostate measuring 6.3cm with calcification is found.
      • The GB is well distended without soft tissue lesion
      • S/P NG tube placement.
      • The spleen, pancreas and adrenals are intact.
      • Very small nodule at hepatic hilum measuring 0.8cm in largest dimension. In comparison with CT dated on 2022-10-12, the lesion regressed.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Visible chest
        • Normal heart size.
        • Calcified coronary arteries is found.
        • The lung fields are clear.
    • Imp:
      • Hepatic hilar nodule. In regression.
      • Enlarged prostate. 6.3cm
  • 2023-01-05 Nasopharyngoscopy
    • Hypo ca undergoing CCRT
    • NG+
    • saliva stasis
  • 2022-11-03 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-10-27 ECG
    • Sinus tachycardia
    • T wave abnormality, consider anterior ischemia
  • 2022-10-12 CT - abdomen
    • Indication:
      • Poor intake after R/T, dysphagia, odynophagia
      • 68 y/o male, a pt of Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT= suspect liver mets) Dx in Aug 2022
    • Findings
      • Regression of S1 liver lesion (or hepatic hilar lesion), from 1.9cm to 1.0cm.
      • Right kidney cyst, 5.2cm.
      • No ascites or extraluminal free air.
      • No evidence of bowel obstruction.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • Enlargement of prostate gland.
      • No bony destructive lesion on these images.
    • Impression
      • Regression of S1 liver lesion (or hepatic hilar lesion)
      • Prostate enlargement
  • 2022-09-15 Nasopharyngoscopy
    • 202208 Hypo ca, R+ neck mets(R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets) = wish
    • 20220915 fiber = new R vocal palsy + supraglottic smooth bulging progress + no glottis visible (no dyspnea) + mucopus
  • 2022-09-06 Patho - odontogenic/dental cyst
    • Labeled as “granulation tissue in the extraction socket of tooth 34”, removal — Granulation tissue
    • Section shows benign squamous mucosa lined granulation tissue composed of proliferative small blood vessels, fibrosis, and moderate diffuse acute and chronic inflammation.
  • 2022-08-29 CT - abdomen
    • Liver low density lesion at S1, liver meta is favored.
    • Enlarged prostate. Please correlate with PSA.
  • 2022-08-25 Esophagogastroduodenoscopy, EGD
    • Right hypopharynx mass
    • Gastric ulcers, antrum
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Superficial gastritis, s/p CLO test
  • 2022-08-25 SONO - abdomen
    • Prob. Parenchymal liver disease
    • Bil renal cysts
  • 2022-08-23 Patho - larynx biopsy
    • Labeled as “right hypopharyngeal tumor”, additional biopsy (S2022-13982) for formalin fixation — squamous cell carcinoma (SCC). IHC stains: p16 (-), Ki-67: 10-15%.
    • Labeled as “right hypopharyngeal tumor”, initial biopsy with frozen section examination (F2022-391) — squamous cell carcinoma in situ (CIS), at least.
  • 2022-08-23 Frozen section
    • Preliminary diagnosis: right hypopharynx, squamous cell carcinoma in situ (CIS), at least.
  • 2022-08-22 Whole body PET scan
    • Glucose-hypermetabolic lesions in the right hypopharynx, highly suspected the primary hypopharyngeal cancer, suggesting biopsy for investigation.
    • Glucose hypermetabolic lesions in lymph nodes in bilateral cervical regions and in the right supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected cancer with distant metastasis. However, another primary cancer (HCC) should be excluded.
    • Suspected benign lesions in the lesser curventure of the stomach, and physiological uptake of FDG in the colon.
    • Right hypopharyngeal cancer with bilateral cervical and right SCF lymph nodes and liver metastases, cTxN2cM1, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-08-19 MRI - larynx
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:4a(T_value) N:2b(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • 2022-08-18 CT - neck
    • IMP: Right hypopharynx CA with neck LAPs. T4aN2BMx. stage IVA
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2022-08-18 Nasopharyngoscopy
    • Findings
      • 3x3 cm palpable non-tender mass over right neck Level I-II region
      • Scope: bilateral intact ear drums, smooth nasopharynx, oropharynx
        • mass lesion over right AE fold, with moderate airway patency
      • Diagnosis and conclusion
        • right hypopharynx mass, cause to be determined
  • 2021-04-09 KUB
    • The psoas shadow is clear.
    • There is no evidence of destructive bone lesion.
    • Calcified dot(s) is found at left paravertebral region, ureter stone(s) is most likely.
    • Increased intestinal gas is found.

[consultation]

  • 2023-04-16 Ear Nose Throat
    • Q
      • Chief Complaints: just done C/T 1 month ago.
      • progressive dyspnea, productive cough today.
      • Past History: hypophagreal ca cT4aN2bM1 sp CCRT. liver metastasis
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • Stridor for 20 days.
      • Scope: smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold (compared to 202303)
      • Imp: Supraglottic sweillng, suspect C/T related or acute infection
    • Plan:
      • Failed NG insertion due to supraglottic swelling, may consult GI man for insertion
      • Monitor airway, informed the risk of tracheostomy, prescribed Bosmin (adrenalin) + steroid inhalation, IV steroid (if no contraindication)
  • 2022-10-27 Metabolism and Endocrinology
    • Q
      • The 64 y/o man has DM, HCVD and R hypopharyngeal CA wt bil cervical & R SCF LNs & liver mets, cTxN2cM1, stage IVC. He just did chemotherapy on 2022/10/18. Due to weakness and hyperglycemia noted, suspect DKA, so the RI pump use from ED. We need your help for management. Thanks!
    • A
      • We were consulted for blood sugar control.
      • O:
        • BH: 162 cm, BW: unknown
        • Diet: NPO except water and drugs
        • Medication in OPD: unknown
        • Medication during hospitalization: RI pump 30 ml/hr
        • Na: 123, K: 5.4, Ca: 2.75
        • ALT: 32
        • BUN/Cr: 71/1.95 (eGFR: 36.54)
        • F/S: 275
        • Blood glucose: 673 mg/dL
        • HbA1c: unavailable
        • Blood osm: 317, effective osm: 283
        • Urine ACR: unavailable
        • OPH OPD: nil
      • A: Type 2 DM, poor control
      • Suggestions:
        • Avoid all OADs. Keep NPO except water and drugs
        • RI pump 50U in 500ml N/S run as protocol
        • H/S 500ml Q12H, 0.298% KCl QD + STAT (STAT after serum K reading)
        • Check F/S Q2H. Check Na, K, vein gas Q8H until off RI pump
        • Switch to basal bolus therapy later. (contact us to adjust)
        • Check HbA1c, urine ACR
        • Consult OPH for DM retinopathy if his condition is stable.
        • Consider to consult nutritionist for DM diet education (self-paid approximate TWD 600)
        • Basic educations for Diet control, Hypoglycemic precautions, DM complications and Self-Monitoring of Blood Glucose were given at bedside
        • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.
  • 2022-08-18 Ear Nose Throat
    • Q
      • Right neck pain for 1 month
      • Never seek medical help, only took pain-killers and then tarry stool noted. called at our GI OPD this morning. EGD was arranged for R/O UGI bleeding.
      • Right ear tingling pain, horseness also noted
      • Odynophagia (+)
      • No fever noted
      • Occupation: Taxi driver
      • Medication: Bokey for
      • Past hx: DU, DM
      • OP hx: renal stone s/p op
    • A
      • S
        • sore throat with FB sensation for a month
        • fair saturation under room air
        • odynophagia(+), dysphagia(-), dyspnea(-),stridor (-), mouth drooling(-), voice change (+), otalgia (+, right), fever(-), alcohol(+), smoking(+), betelnut(-)
      • O
        • 3x3 cm palpable non-tender mass over right neck Level I-II region
        • Scope:
          • bilateral intact ear drums, smooth nasopharynx, oropharynx
          • mass lesion over right AE fold, with moderate airway patency
      • A
        • Impression: Right hypopharynx or larynx tumor with neck mass, r/o metastasis
      • P
        • inhalation therapy with steroid + bosmin if no contraindication
        • keep monitor breathing pattern and saturation, intubation or cricothyrodectomy may be considered then if s/s worsen
        • we will f/u the patient

[chemotherapy]

  • 2023-03-15 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-08 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-01 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-18 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-11 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-04 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-26 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

UFT (tegafur 100mg + Uracil 224mg) KUFT01

  • 2023-02-02 ~ undergoing - 2# BID
  • 2022-08-29 ~ 2022-10-03 - 2# BID

[assessment]

  • For the patient’s shortness of breath (SOB), in addition to the currently prescribed Ipratran (ipratropium bromide), the addition of Butanyl (terbutaline) could be considered if there are no contraindications. Inhaled glucocorticoids such as beclomethasone, budesonide, ciclesonide, fluticasone, mometasone and triamcinolone may also be considered.

701010079

230417

[exam findings]

  • 2023-03-24 MRI - pelvis
    • CC: Stool passage from urine, hematuria, turbid urine
      • 20210111 CT: Rectal cancer,T4bN2aM0,STAGE:IIIC. Rectal-vesical fistula.
      • 20220413 CT: Soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • 20230218 CT: soft tissue mass at left lateral pelvis with left hydroureteronephrosis.
      • 20230223 TURBT of Bladder tumor: Adenocarcinoma c/w colorectal origin.
    • Past History: Liver abscess S/P right hepatectomy, old TB
    • Findings:
      • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
        • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
        • In addition, rectal-vesical fistula is noted.
      • There is no evidence of left hydroureteronephrosis.
      • There is no focal abnormality in the prostate.
        • Non-visualization of the seminal vesicle is noted.
      • There is no evidence of ascites or lymphadenopathy.
      • The visible abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
        • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
        • In addition, rectal-vesical fistula is noted.
      • No evidence of left hydroureteronephrosis.
  • 2023-02-27 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor type: colorectal adenocarcinoma with bladder invasion
      • Tumor location: urinary bladder
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark ULTRA
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): <1%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >=1% and <5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 2%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-02-27 PD-L1 IHC
    • Tumor cell (TC) staining assessment:
      • TC: <1%
  • 2023-02-27 PD-L1 (22C3)
    • Combined Positive Score (CPS) assessment: CPS >= 10
    • Combined Positive Score (CPS): 15
  • 2023-02-23 Patho - urinary bladder TUR
    • Bladder tumor, TURBT — Adenocarcinoma, compatible with colorectal origin
    • Microscopic examination
      • Histologic type: Adenocarcinoma, compatible with colorectal cancer with bladder invasion
      • Histologic grade: moderately differentiated
      • Tumor configuration: tubular, cribriform or papillary tumor with focal necrosis and muscle invasion. Besides, normal colonic mucosa is also included in the submitted specimen
      • Immunohistochemistry: CK7(+, scatter), CK20(+), GATA-3(-), CDX2(+) and P63(-) for tumor
      • Clinical correlation is advised.
  • 2023-02-22 CXR
    • Fibrocalcified infiltrates in right upper lung.
    • Right lower lung nodule, 0.9cm, stationary.
  • 2023-02-18 CT - abdomen
    • Indication: new bladder cancer, colon cancer history
    • Abdominal CT without IV contrast ehnancement shows:
      • The urinary bladder is collapsed with thick wall and suspeced soft tissue infiltration to perirectal region measuring 5.65*3.03cm in largest dimension. In comparison with CT dated on 2022-04-13, the lesion enlarged. Suggest further treatment.
      • Left hydronephrosis and hydroureter obliterated by the tumor mass is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Visible chest
        • Calcified coronary arteries is found.
        • Normal heart size.
        • One calcified dot at right lower lobe is found measuring 0.45cm in largest dimension. Old insult is considered.
        • No pleural effusion is found.
    • IMP: Soft tissue mass at bladder base with left hydronephrosis and hydroureter. Uroepithelial cancer is favored.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-12-09 Patho - urinary bladder TUR
    • Urinary bladder, TURBT — high-grade invasive urothelial carcinoma. Muscularis propria not present.
    • Microscopically, section showsinvasive urothelial carcinoma characterized by papillary architecture of the neoplasm lined by high-grade atypical urothelial cells. The tumor cells have irregular nuclear contours with hyperchromasia and pleomorphism, variably prominent nucleoli and mitotic activity. The tumor has invaded subepithelial connective layer. Muscularis propria is not present.
  • 2022-12-07 SONO - nephrology
    • left severe hydronephrosis
  • 2022-04-13 CT - abdomen
    • History: 20210111 CT:rectal cancer with rectal-vesical fistula, cT4bN2aM0, cStage: IIIC
    • Past History: Liver abscess S/P right hepatectomy, old TB
    • Findings:
      • S/P right hepatectomy and S/P cholecystectomy.
      • S/P right transverse colostomy
      • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
      • Fibro-calcified shadows of right upper lung are noted, which is c/w old TB.
    • Impression:
      • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
  • 2021-09-11 CT - abdomen
    • NO evidence of tumor invasion into urinary bladder is found.
    • The urinary bladder is collaped with thick wall. Although no tumor invasion is found in the current study. Cystoscopy is suggested if hematuria persisted.
    • Right lower lobe nodule, in regression.
  • 2021-01-26 CT - chest
    • Indication: rectal intramucosal adenocarcinoma, Chest x-ray showed right lung nodule
    • MDCT (256-detectors, GE Revolution, was performed with 0.625 mm collimation & 1.25 mm slice thickness) of the chest without contrast enhancement, coronal and sagittal reformatted images and axial MIP images obtained shows:
      • Lungs:
        • reticular and nodular opacities with architextural distortion in RUl. reticular opacities in anterior RLL.
        • two solid nodules in RLL (up to 9 mm in largest axial dimension) and snother smaller solid nodule in RML.
      • Mediastinum and hila: no enlarged LN or mass.
        • old calcified LNs in the mediastinum and hila, sequela of previous TB infection
      • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: Rt apical pleural thickening.
      • Chest wall: unremarkable.
      • Visible abdominal contents: s/p Rt hepatic posterior segmentectomy.
      • Visualized bones: no lytic or blastic lesion.
    • Impression:
      • three solid nodules in Rt lung, firstly considered metastases.
      • post inflammatory fibrotic change in RUL and anterior RLL.
  • 2021-01-25 CXR
    • Interstitial pattern at RUL.
    • A nodule at right middle lung zone.
    • Blunted right costophrenic angle.
  • 2021-01-19 Patho - colorectal polyp
    • Rectal tumor, biopsy — Intramucosal adenocarcinoma at least
    • Microscopically, the sections show a picture of intramucosal adenocarcinoma at least characterized by tumor arranged in cribriform or villous pattern with subtle stromal reaction.
    • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
  • 2021-01-19 Barium Enema (double contrast)
    • LGI series with water soluble contrast medium revealed:
      • Total occlusion of rectum, about 9cm from anal verge. No further passage of contrast medium even on a 10mins delayed image.
      • Plain pelvis CT was performed for comparison and prooved above description.
    • IMP:
      • c/w rectal mass with total occlusion
      • Suggest oral contrast study if a colo-vesical fistula is suspected clinically.
  • 2021-01-19 Colonoscopy
    • Suspected rectal cancer obstruction s/p biopsy
  • 2021-01-11 CT - abdomen
    • History and indication: rectal-vesical fistula
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat stranding and regional LAP. Presence of rectal-vesical fistula.
      • S/P right hepatic lobe operation.
      • Some small LNs at retroperitoneum.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • No ascites.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
      • Degeneration and spondylosis of L-S spine.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)

[chemotherapy]

  • 2023-04-14 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + NS 250mL
  • 2021-05-05 - irinotecan 120mg/m2 180mg D5W 250mL 90min
    • betamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO + NS 500mL
  • 2021-03-29 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-24 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-08 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-04 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2

[assessment]

  • The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.

  • On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.

701091164

230417

[diagnosis] - 2022-11-25 admission note

  • Rectal cancer s/p neoadjuvant concurrent chemoradiotherapy at TP-VGH in 2012, with response of CR, so no OP. Due to near total obstruction on 2018/06, receiving T-colostomy on 2018/06/11 followed by neoadjuvant radiotherapy for 17 doses, then neoadjuvant FOLFOX or CapOx for 3 cycles, subsequently receiving APR on 2018/10/11, and then FOLFOX or CapOx for 9 cycles (to 2019-05) at TSGH in 2018 with lung metastases.
  • Malignant neoplasm of colon, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Chronic kidney disease, stage 5
  • Hyperuricemia
  • hypertension
  • Constipation
  • Anemia due to antineoplastic chemotherapy

[past history]

  • Hypertension for years with drug control,
  • CKD stage 5,
  • colorectal cancer s/p operation on 2018 and 2019,
  • Right ureteral stricture with hydronephrosis s/p D-J since 2020.
    • 3-6 months to replace the DBJ regularly
    • Last changed right DBJ in June (at TSGH)

[allergy]

  • penicillin

[family history]

  • Mother had hypertension and diabetes.
  • There is no family history of cancer, mental diseases or asthma.

[exam findings]

  • 2023-03-21 CT - abdomen
    • WITHOUT contrast enhancement CT of abdomen - whole:
      • S/P colostomy, presence of ventral herniation.
      • Soft tissue tumor in presacral region with urinary bladder wall involvement.
      • Hyperdensity in the urinary bladder.
      • S/P double J catheter drainage, right side.
      • S/P PCN catheter drainage, left side.
      • Presence of gallbladder stones.
      • R/O liver cysts, up to 4.7cm in left lobe.
      • Bilateral lung tumors, stationary.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • S/P colostomy, presence of ventral herniation.
      • Soft tissue tumor in presacral region with urinary bladder wall involvement.
      • Hyperdensity in the urinary bladder, hematoma? or tumor.
      • S/P double J catheter drainage, right side. S/P PCN catheter drainage, left side.
      • GB stone.
      • R/O liver cysts.
      • Bilateral lung tumors, stationary. Suspected lung metastasis.
  • 2023-02-14 KUB
    • S/P double J catheter insertion in place, right side.
    • S/P PCN catheter drainage, left side.
    • Lumbar spondylosis.
    • Non-specific bowel gas pattern.
    • Calcifications in the pelvic cavity, could be due to phleboliths.
  • 2023-02-13 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-02-01 Nasopharyngoscopy
    • smooth nasopharynx,oropharynx, hypopharynx
    • pale and boggy inf. turbinate, with clear mucus, erosion wound over inferior turbinate and nasal septum
    • intact ear drum with cerumen, s/p removal
  • 2022-10-31, -10-06, -09-22 SONO - kidney
    • Bilateral hydronephrosis
  • 2022-10-24, -10-19 CXR
    • Atherosclerotic change of aortic arch
    • Few nodular opacity projecting in both lower lung are noted that are c/w metastases after correlate with CT.
  • 2022-10-19 CXR
    • Septal infarct, age undetermined
  • 2022-09-20 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • There was no variant detected in the KRAS/NRAS gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-15 PET scan
    • Glucose hypermetabolism in the posterior lower pelvic region, compatible with a metastatic lesion.
    • A glucose hypermetabolic lesion in the lower lobe of left lung, compatible with lung metastasis.
    • Two mild glucose hypermetabolic lesions in the right lung. Metastatic lesions can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2022-09-14 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, and increased activity in bilateral pubic bones, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
  • 2022-09-14 Bladder Sonography
    • PVR (post-void residual volume) 16.79 ml
  • 2022-09-13 PD-L1 (22C3)
    • Combined Positive Score (CPS) category: CPS >= 1 and < 10
    • Combined Positive Score (CPS): 2
  • 2022-09-13 PD-L1 (SP142)
    • Result:
      • Tumor Cell Staining Assessment:
        • PD-L1 Expression: Absent (TC = 0%)
      • Tumor Infiltrating Immune Cell Staining Assessment:
        • PD-L1 Expression: 10% Immune cells (IC= 10%)
    • Note:
      • Percent of PD-L1 expression in tumor cells (TC):
        • The percentage of viable tumor cells with membrane positivity at any intensity
      • Percent of PD-L1 expression in immune cells (IC):
        • The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
  • 2022-09-13 PD-L1 (IHC)
    • Result:
      • Tumor cell (TC) staining assessment: 0%
      • Combined Positive Score (CPS) assessment: 0.1
  • 2022-09-12 CT - abdomen
    • S/P colostomy with incisional hernia and small bowel ileus.
    • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
    • Lung metastases.
  • 2022-09-09 Body fluid cytology - urine
    • DIAGNOSIS: atypia;
    • GROSS DESCRIPTION: 15 ml turbid clear
    • MICROSCOPIC DESCRIPTION: numerous neutrophils and many atypical urothelial cells present. Further work up, including biopsy or tumor excision, may be considered.
  • 2022-09-08 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Urianry bladder, posterior wall, left, TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of seven small pieces of gray-brown soft tissue, labeled “bladder tumor, left posterior wall”, measuring up to 0.4 x 0.3 x 0.1 cm. All for sections.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arranged in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
      • Histologic grade: Moderately differentiated
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades subepithelial connective tissue
      • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin (extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
      • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma is most likely
  • 2022-09-08 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Prostatic urethra, TURBT — Adenocarcinoma, enteric type, favors metastatic colonic carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of gray-brown soft tissue, labeled “prostatic urethra”, measuring 2.0 x 1.5 x 0.4 cm in aggregate. All for sections.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arragned in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
      • Histologic grade: Moderately differentiated
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
      • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin(extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
      • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma most likely
  • 2022-09-01 SONO - nephrology
    • Bilateral hydronephrosis with hydroureter, mild to moderate degree. (right kidney is more prominent)
    • Right chronic parenchymal renal disease.
    • Double J catheter in situ, right kidney.
    • Urinary retention, suspected neurogenic bladder.
    • Gall bladder stones.
  • 2022-09-01 Bronchial Dilator Test
    • normal, FEV1/FVC = 81%, FVC = 93%, FEV1 = 95%
    • without significant reversibility
  • 2022-08-26 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Ground glass nodule at posterior segment of right upper lobe up to 0.47cm in largest dimension is found.
        • One spiculated nodule at subpleural space of right middle lobe up to 0.88cm in largest dimension is found. Another lobulated nodule at left lower lobe up to 1.9cm is found. Lung meta is favored.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • Bulging renal tumor at left side up to 2.83cm in largest dimension. Nature?
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp:
      • Right upper lobe ground glass nodule, suggest follow up.
      • Right middle lobe and left lower lobe nodules, lung meta is favored.
      • Left renal tumor.
  • 2022-08-25 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Subtle nodular opacity over Lt retrocardiac lower lobe

[consultation]

  • 2022-09-13 Colorectal Surgery
    • Q
      • For Ventral hernia with intestines herniation and ileus
      • Colon cancer s/p operation on 2018 and 2019 at Tri-Service General Hospital (APR and hemicolectomy?)
      • Abdomen CT (20220912) showed parastomal hernia and lung metastases.
      • The patient is a case of bilateral hydronephrosis, was admitted for surgery of URS.
      • At admission, he accepted antibiotics with flumarin therapy due to urine culture (2022-09-01) showed Klebsiella pneumoniae. Preoperative evaluation and examination were done. Anemia (HGB: 7.9) was found and BT LPRBC 2U. The same day, PPI was given due to vomiting multiple times also found and the vomit showed coffee. Consultation Nephrology for renal function impairment (BUN 124 mg/dL, Cr 8.52->10.36mg/dL).
      • Post TURBT, Left PCN and right URS on 2022-09-08. After surgery, abdomrn fullness also found and KUB showed focal small bowel ileus. Due to no drainage from the left PCN, antegrade pyelography (2022-09-09) was done and which showed dislodgement of the pigtail over left side; Ventral hernia with intestines herniation is found. Ileus is also noted. Therefore, left PCN re-insertion was done on 20220909.
      • He complained small amount of vomiting per day. Abdomen distention still was noticed. Abdomen CT showed parastomal hernia and lung metastases.
      • We need your help for further evaluation and management. Thanks for you.
    • A
      • O:
        • Abdomen: soft, parastomal hernia(+), no tenderness, no distended or rigidity
        • Colostomy: pass flatus or stool(+)
        • TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
        • 20220912 CT
          • S/P colostomy with incisional hernia and small bowel ileus.
          • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
          • Lung metastases.
      • A:
        • Para-stomal hernia, without bowel incarceration or strangulation
        • Favor local recurrence of rectal adenocarcinoma in low pelvic region
      • P:
        • Please check CEA, and arrange PET scan for more cancer evaluation
        • We would like to follow this patient and make decision for further management
  • 2022-09-08 Nephrology
    • A
      • S
        • This 66 years old male patient had underlying history of hypertension, CKD stage 5 and colon cancer s/p op and right hydronephrosis s/p DJ since 2020.
        • Consult for renal function impairment
      • O
        • Lab data:
          • Na: 132, K:4.2, albumin: 4.5
          • WBC: 9.49, Hb: 7.9, Plt: 320
          • BUN: 124, cre: 8.52 -> 10.36
        • Renal echo (20220901): bilateral hydronephrosis with hydroureter (DJ in right kidney), distended urinary bladder with urine retention
        • U/O: 652ml under foley
      • Assessment
        • Acute kidney injury on CKD stage 5, suspect post renal with bilateral hydroneophrosis and hydroureter
      • Suggestion
        • Keep Foley patent, record U/O and BW qd.
        • DC exforge, if BP is high, you may add norvasc
        • Give Recormon 500U sc qW for renal anemia
        • Follow up BUN, cre, Na, K, Ca, P, CO2 or VBG
      • Consider HD if refractory hyperkalemia, metabolic acidosis or pulmonary edema is noted.

[chemotherapy]

  • 2023-04-17 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-03-22 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-03-03 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-01-16 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2022-12-28 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-11-30 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-11-08 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-10-21 - leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI without Iri)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-09 - mitomycin-c 30mg/m2 30mg 1hr BI (bladder irrigation)

==========

2023-04-17

  • The patient’s renal function appears to be declining recently, which should be noted.
    • 2023-04-17 Creatinine 2.59 mg/dL
    • 2023-04-06 Creatinine 2.50 mg/dL
    • 2023-03-16 Creatinine 2.07 mg/dL
    • 2023-04-17 eGFR 26.50
    • 2023-04-06 eGFR 27.60
    • 2023-03-16 eGFR 34.32
    • 2023-04-17 BUN 49 mg/dL
    • 2023-04-06 BUN 38 mg/dL
    • 2023-03-16 BUN 35 mg/dL
  • The patient has undergone 7 blood transfusions since September 2022, and elevated ferritin levels of 596 and 545 ng/mL were observed in the last quarter of 2022. Kentamin (B1, B6, B12) has been administered, and the patient’s MCV, MCH, and MCHC levels are normal as of 2023-04-17, making iron deficiency less likely. It is advised to reassess the patient’s iron storage before determining if iron supplements are necessary. Currently, Foliromin (ferrous sodium citrate) is prescribed.

2023-03-22

  • This patient has CKD stage IIIb-IV (eGFR 15-44) and has not undergone dialysis. The patient has received 5 blood transfusions since September of last year and 1 in March of this year. Updated lab results from 2023-03-16 show normal MCV, MCH, and MCHC, but a decreased HGB level of 9.7g/dL, suggesting that iron-deficiency anemia is less likely. The patient’s lab history indicates high ferritin levels of 596 and 545 ng/mL in the last quarter of 2022. The current prescription includes Foliromin (ferrous sodium citrate). It is recommended to assess the patient’s iron storage to determine if iron supplementation is necessary.
  • In accordance with the current National Health Insurance medication reimbursement regulations, EPO - hu-erythropoietin such as Eprex and Recormon) and darbepoetin alfa (such as Aranesp) can be used for chemotherapy-related anemia in cancer patients with solid tumors who have symptomatic anemia and Hb<8 gm/dL. And the regulation requires that EPO treatment should not be used for cancer patients who are expected to have reasonable and sufficient survival time, including curative and expected adjuvant chemotherapy.

2023-01-17

  • His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.

    • 2022-12-13 Ferritin 596.5 ng/mL
    • 2022-11-22 Ferritin 454.2 ng/mL
  • High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.

  • As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.

  • By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.

2022-12-29

  • The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.

    • 2022-12-28 MCV 89.7 fL
    • 2022-12-28 MCH 29.2 pg
    • 2022-12-28 MCHC 32.5 g/dL
    • 2022-12-13 Ferritin 596.5 ng/mL
    • 2022-12-13 Fe (Iron-bound) 32 ug/dL
    • 2022-12-13 TIBC 189 ug/dL
    • 2022-12-13 UIBC 157 ug/dL
    • 2022-11-22 Ferritin 454.2 ng/mL
    • 2022-11-22 Fe (Iron-bound) 42 ug/dL
    • 2022-11-22 TIBC 197 ug/dL
    • 2022-11-22 UIBC 155 ug/dL
  • Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.

  • It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.

2022-11-28

  • 2022-11-22 lab results showed a low serum iron concentration (42 mcg/dL, normal range 60 to 150 mcg/dL), as well as a low transferrin level (TIBC 197 mcg/dL, normal range 300 to 360 mcg/dL), which resulted in a transferrin saturation level of 21% at the lower end of the normal range (20%~45%). In the meantime, ferritin levels increased (545 ng/mL, normal ranges, 30 to 200 mcg/L for women and 30 to 300 mcg/L for men, prior to the planned transfusion).
  • Inflammatory conditions in which cytokine production might lead to altered iron trafficking and decreased production of RBCs. The underlying condition could be a chronic kidney disease or a malignancy.
  • Upon discovery of a serum ferritin level exceeding 1000 mcg/L, a daily dose of 14mg/kg of Jadenu (deferasirox, available at this hospital) with regular serum creatinine monitoring might also be an optional add-on.

2022-11-09

  • Insufficient renal function, 2022-11-02 serum Cre was 2.42mg/dL, BUN was 34mg/dL, and eGFR was 28.66. The active prescription has been well-adjusted to reflect the patient’s renal function.
  • The patient is being administered irinotecan (at a lower dose of 50mg/m2) for the first time. Irinotecan can cause early and late forms of diarrhea. Early diarrhea may be accompanied by cholinergic symptoms which has been dealed with prescribed subcutaneous premedication atropine. In the event of late diarrhea, loperamide should be administered as soon as possible. Please monitor the patient for signs of diarrhea.

2022-10-20

  • This is a patient with rectal cancer who underwent an abdominoperineal resection and a T-colostomy and treated with FOLFOX/CapeOx at Tri-Service General Hospital in 2018.
  • 2022-09-20 All-RAS and BRAF assay showed no detected variant in the KRAS/NRAS/BRAF gene. Treatment with anti-EGFR antibodies might be beneficial. The use of encorafenib would not be preferred.
  • The level of PD-L1 expression was low (outsourced lab results in late Sep 2022). This might limit the use of immunotherapy methods that involve PD-L1.
  • FOLFOX/CapeOx has previously been used, so FOLFIRI (+ bevacizumab or + cetuximab or panitumumab) might be considered as a possible treatment option.
  • Neither fluorouracil nor leucovorin nor irinotecan dosage adjustments are provided in the manufacturer’s labeling for the FOLFIRI regimen in patients with impaired kidney function (2022-10-20 Cre 2.54 mg/dL, eGFR 27.10).

701447197

230417

[diagnosis] - 2023-04-06 admission note

  • Infectious gastroenteritis and colitis, unspecified
  • Diffuse large B-cell lymphoma, lymph nodes of multiple sites
  • Cardiomegaly
  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Diffuse large B-cell lymphoma, spleen
  • Hypertensive heart disease without heart failure
  • Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-06 admission note

  • Hypertension for 15 years with drug control
  • Hyperlipidemia for 15 years
  • Gout for 15 years        
  • COVID-19 positive on 2022/10    
  • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys) , Lugano stage IV, IPI score2 s/p chemotheraphy
  • Multiple myeloma, IgG kappa type, ISS stage II            

[allergy]

  • Mobic 7.5mg/tab (meloxicam): skin rash

[family history]

  • No known congenital or systemic disease.
  • Family history is unremarkable.
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-04-06 CXR
    • Ground glass opacity in RLL.
    • Cardiomegaly.
  • 2023-03-28 PET
    • The FDG PET findings are compatible with lymphoma in bilateral pulmonary hilar and mediastinal lymph nodes, bilateral lungs, spleen and bone marrow (stage IV). However, in comparison with the previous study on 2022/08/17, the previous glucose hypermetabolic lesions are either less evident or disappeared, suggesting partial response to the therapy.
    • Increased FDG accumulation in bilateral renal pelvis. Physiological FDG accumulation is more likely.
  • 2023-03-27 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are few nodular opacities projecting in both lung. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-17 CT - chest
    • Indication:
      • Triple cancer, synchronous (lymphoma, myeloma, bladder ca)
      • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugan 0 stage IV, IPI 2.2: Multiple myeloma, IgG kappa type, ISS stage II
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse nodular lesiona are found at bilateral lung fields (n>10). In comparison with CT dated on 2022-12-05, the numbers are decreased.
        • Small lymph nodes are found at right paratracheal and AP window.
        • Patent airway is found.
        • Mild bilateral pleural effusion is found.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Bilateral renal cysts are found.
        • Low density lesion at spleen is found. Stable.
        • The spleen, liver, pancreas and adrenals are intact.
    • IMp:
      • Bilateral lung nodules, decresaed in numbers
      • Mediastinal small lymph nodes
  • 2023-02-19, -02-03, -01-19, -01-06 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are few nodular opacities projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-01-06 ECG
    • Atrial fibrillation
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-12-28 Patho - urinary bladder TUR
    • Urinary bladder, left lateral wall, TUR-BT — Urothelial carcinoma (high grade), focally invading muscularis prorpia.
    • Section of the larger piece and the smaller piece show urothelial carcinoma composed of papillary structures lined by urothelial cells with enlarged, hyperchromatic nuclei, high N/C ratio and mitoses. The larger piece shows focal invasion of muscularis propria. The smaller piece shows no muscularis propria.
    • IHC stains: GATA-3 (+), SMA highlight muscularis propria in the larger tissue. The smaller tissue shows no muscularis propria.
  • 2022-12-27 ECG
    • Atrial flutter with variable A-V block
    • Possible Inferior infarct , age undetermined
  • 2022-12-27 CXR
    • Fibrotic infiltrates in right upper lung.
    • Consolidation in right lower lung.
    • Blunting of costophrenic angle, left side, could be due to pleural effusion.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2022-12-05 CT - abdomen
    • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys), Lugano stage IV, IPI 2
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • Bilateral renal cysts are found.
      • The liver, pancreas and adrenals are intact.
      • Irregular shaped low density change at spleen up to 3.06x2.6cm is found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • One filling defect at lateral wall of the bladder base up to 1.2cm in largest dimension. Bladder uroepithelial cancer is considered. In comparison with CT dated on 2022-08-31,
      • The GB is well distended without soft tissue lesion
      • Small lymph nodes are found at paraaortic region. In regression.
      • Visible chest
        • Cardiomegaly is noted.
        • Nodular leisons at both lungs is found. In regression.
        • Increased pulmonary vasculature is found.
        • NOn-specific lymph nodes are found in the mediastinum.
    • Imp:
      • Mediastinal lymphadenopathy and splenic and lung involvement. The lung involvement regressed.
      • Bladder tumor, suspected uroepithelial cancer.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-12-27, -11-25, -11-18 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2022-10-26 CXR
    • Cardiomegaly.
    • Multiple nodules at bil. lungs.
  • 2022-10-26 Panendoscopy
    • Diagnosis
      • Gastric ulcers, multiple, antrum, low and mid body
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
    • Suggestion
      • please search for other possible bleeder.
  • 2022-10-21, -10-11, -09-14 CXR
    • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-09-28 Panendoscopy
    • Diagnosis
      • Gastric ulcers, Forrest classification type IIa, GC site of middle body, s/p hemostasis with APC
      • Gastric ulcers, multiple, GC/PW site of antrum, AW site of low body and middle body
      • Reflux esophagitis LA Classification grade A
      • Esophageal hematoma, EG junction, suspect NG tube friction related
      • Superficial gastritis
    • Suggestion
      • High dose PPI use
      • Consider second-look endoscopy if ACITVE BLEEDING sign or PERESISTED Tarry stool.
  • 2022-08-31 CT - abdomen
    • Findings
      • There are bilateral inguinal hernia with small bowel and omentum fat herniation on right side and omenum fat on left side.
        • In addition, fatty stranding and fluid collection in right inguinal hernia sac is suspected that may be incaceration? please correlate with clinical condition.
      • There are multiple soft tissue lesions on both lung that may be lymphoma?
      • There is a low density mass measuring 4.5 cm in the spleen that may be lymphoma involvement.
      • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that may be lymphoma.
      • There is a soft tissue mass measuring 2 cm in left lateral wall of the urinary bladder. Please correlate with cystoscopy to R/O lymphoma or urothelial cell carcinoma?
      • There are several renal cysts on both kidney and the largest one measuring 4.3 cm in size at right upper pole.
    • Imp
      • Incaceration of right inguinal hernia is highly suspected.
  • 2022-08-28 CXR
    • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Enlargement of cardiac silhouette.
  • 2022-08-25 SONO - nephrology
    • There are two mass lesions 2.34cm and 1.51cm in the lateral and inferior wall of urinary bladder, suspected bladder tumors.
    • Bilateral renal cysts.
    • Parenchymal renal disease.
  • 2022-08-18 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with plasma cell myeloma and free from lymphoma involvement
    • Microscopic Examination
      • Hypercellularity of bone marrow for his age
      • Marked Increased plasma cells, more than 90%, highlights by CD138 and CD117 IHC stains and favor kappa light chain restriction
      • M/E ratio about 1/3 with marked hypoplasia of both series highlights by CD71 and MPO IHC
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation, highlights by CD61 IHC
      • no increase of blast, highlights by CD34 IHC
      • No B-cell lymphoma involvement, CD20 IHC shows scant and scatter positive
      • According to all above histopathologic findings, it is compatible with plasma cell myeloma and free from lymphoma involvement. Clinical and laboratory correlation is advised.
  • 2022-08-17 Whole body PET scan
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal lymph nodes, lymph nodes in the upper to mid-abdomen, a lymph node in the lateral aspect of the left upper thigh region, bilateral lungs, stomach, spleen, and both kidneys (Deauville score 5 in all above-mentioned lesions), highly suspected lymphoma with diffuse involvement of more extralymphatic organs with associated lymph node involvement.
    • Glucose hypermetabolism in the L2 spine (Deauville score 4) and in the right lobe of the thyroid gland (Deauville score 5), the nature is to be determined, suggesting further investigation.
    • Lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-08-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 39) / 126 = 69.05%
      • M-mode (Teichholz) = 69
    • Mild septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; severely dilated LA.
    • Mildly dilated LV with normal LV and RV systolic function.
    • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
    • Dilated proximal ascending aorta (46mm) with mild calcification.
  • 2022-08-15 CXR
    • Nodular lesions in both lung fields

[consultation]

  • 2022-09-27 Gastroenterology
    • Q
      • vomiting blood and bloody stool today
      • genrenal weakness was noted
      • no dizziness, no dyspnea, no abdominal pain
      • PH: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys) , Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
      • NKA
    • A
      • S
        • 71M
        • Phx: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
        • CC: Vomiting blood and bloody stool today
        • NPO: 20220927 12:00
      • O
        • BP: 103/62, HR:81, Conscious clear, under N/C, SpO2: 100
        • Hb: 7(9/26)-> 6.3(9/27)
        • PLT: 136(9/27)
        • INR:1.27
      • A
        • Hematemesis, suspect upper GI bleeding
      • P
        • EGD is indicated for this patient, but NPO duration is not adequate, give high dose PPI first. We will arrange EGD tomorrow
        • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
        • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
        • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock
  • 2022-09-21 Urology
    • Q
      • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2 and multiple myeloma.
      • Due to bladder tumor noted and sometimes has hernia bulge, so we need your help for assessment. Thanks!
    • A
      • This patient has diffuse large B cell lymphoma and multiple myeloma.
      • This time he was admitted for 2nd R-COP chemotherapy.
      • CT: 2cm bladder tumor at left lateral; hernia: 20220831 incarceration, GS was consulted and manual reduction was performed
      • impression: 1. bladder tumor 2. right inguinal hernia suspected incarceration
      • Plan:
        • arrange scrotal echo for suspected incarceration
        • arrange TURBT and hernia repair, time to be determined
  • 2022-09-21 Rheumatology
    • Q
      • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • Due to gouty arthritis over left knee, so we need your help for assessment. Thanks!
    • A
      • S
        • History review & physical examination were performed. Patient was admitted due to Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
        • I was consulted for Acute L’t knee arthritis. Meanwhile, allergic skin rash was also noted (mobic or uricon-induced?).
      • O
        • RIA condition:
          • Previous GA Hx(+)
          • UA:4.5 -> 7.6 -> 4.7
          • ANA/RF/anti-CCP(-)
          • ALT/Cre:25/0.87
        • erythematous swelling, L’t knee (less effusion than week ago).
      • Suggestion:
        • Treatment as current your expert’s management.
        • Please take L’t knee x-ray, add colchicine 1#BID (if diarrhea, taper to 1#QD), acetaminophen 1#BID & decan 4mg IVD BID x 2-3 days.
        • When recovered from acute stage, please keep colchicine 1#QD & feburic 1#QD.
        • Inform me again if need.

[SOAP]

  • 2022-10-11 Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220905
      • IgG type MM stage 2
      • Diffuse large B cell lymphoma with lung involved stage 4
      • use R-COP first
  • 2022-10-04 Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20230213
      • Hold off on chemotherapy mR-CHOP for now,
      • First complete bladder cancer CCRT.
    • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date, 20220912
      • Synchronous DLBCL and myeloma treatment approach cannot wait due to stage 4 diffuse large B cell lymphoma, so R-COP has been used. Treatment strategy will be determined after review.
  • 2022-09-09 Hemato-Oncology
    • Multi-disciplinary team meeting conclusion for cancer patients, Meeting date: 20220829
      • Diffuse large B cell lymphoma stage 4
      • Multiple myeloma IgG kappa ISS stage 2
      • Bladder tumor nature
    • Assessment
      • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • Multiple myeloma, IgG kappa type, ISS stage II
      • Gastrointestinal hemorrhage, unspecified
      • Anemia
      • Postive of anti-HBc
      • Port-a implement on 2022/08/18
      • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
      • Agranulocytosis secondary to cancer chemotherapy
      • Neutropenic fever
      • Acinetobacter pittii bacteremia
      • Gouty arthritis attack over left knee
      • Groin Hernia
      • Bladder tumor natrure?

[surgical operation]

  • 2022-12-28
    • Surgery
      • Laparoscopic hernia repair, bilateral
      • Laser TUR-BT
    • Finding
      • TEP OP Finding:
        • Main defect:
          • Right
          • type: primary; M, L
          • Size: II
          • Grading: 2
          • incarceration, adhesion
          • Sac contents: omentum
        • Contralateral occult defect:
          • type: M
          • Size: II
        • Trocar number: 3
        • TEP approach
        • Mesh type: heavy weight
        • Mesh size: Left 13x15 cm; Right 12x15 cm
        • Mesh fixation: absorbatack
    • TUR-BT finding:
      • A cauliflower-like tumor at left lateral wall
      • A diverticulum at right posterior wall
      • Bilateral UO with clear efflux
    • Risk evaluation:
      • Tumor size: <=3cm (V), >3cm()
      • Multifocality: Multifocal(), solitary(V)
      • Recurrence within 1 year: Yes(), No(V)

[chemoimmunotherapy]

  • 2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

==========

2023-04-17

  • Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.

  • Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014

  • Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.

2023-04-07

  • On both 2023-01-06 and 2022-12-27, the patient’s ECG showed atrial fibrillation (AF), which is a significant contributor to morbidity and mortality in adults. Additionally, a transthoracic echocardiogram from 2022-08-16 indicated severe dilation of the left atrium. While ischemic stroke resulting from embolization of left atrial thrombi is the most common manifestation of embolization, embolization to other sites in the systemic circulation (as well as the pulmonary circulation from right atrial thrombi) can also occur, albeit less frequently recognized.
  • The patient’s available PLT count data in 2023 ranged from 70K to 245K /uL, touching the upper limit of grade 2 thrombocytopenia (CTCAE v5.0, grade 2: 50K~75K/uL) a few times. Due to the unstable PLT count, LMWH may be preferred over direct oral anticoagulants (DOACs). ref: EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere. 2022;6(8):e750. Published 2022 Jul 13. doi:10.1097/HS9.0000000000000750

2022-10-27

  • Severe, including fatal, mucocutaneous reactions can occur in patients receiving rituximab products. Unless there is no concern for gastrointestinal bleeding, it is recommended to hold R-CHOP therapy for a period of time.

701473049

230417

[diagnosis] - 2023-04-14 admission note

  • T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB s/p chemotherapy with FOLFIRI from 2023/03/29~
  • Anemia due to antineoplastic chemotherapy
  • Chronic obstructive pulmonary disease, unspecified
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Hypokalemia

[past history]

  • Hypertension for 10 years without control

[allergy]

  • NKDA     

[family history]

  • Mother with HTN
  • There is no family history of cancer, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-27 CXR
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Borderline cardiomegaly
  • 2023-03-25 CT - abdomen
    • History and indication: T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP.
      • Multiple lung tumors.
      • Multple bony metastases.
      • R/O left renal angiomyolipoma (1.0cm).
      • Normal appearance of liver, spleen, pancreas, adrenals.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2023-03-24 Patho - colorectal polyp
    • Colon tumor, T-colon, biopsy — Compatible with adenocarcinoma, see description
    • Microscopically, the sections show a picture of almost benign colonic mucosa with scant tumor cells arranged in glandular pattern and desmoplasia. According to clinical information and histopathologic fiinding, it is compatible with adenocarcinoma.
  • 2023-03-23 Colonoscopy
    • Suspected T-colon cancer with partial obstruction s/p biopsy
  • 2023-03-08 Patho - lung transbronchial biopsy
    • Lung, ? side, CT-guide biopsy — in favor of metastatic adenocarcinoma from colorectal origin
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with marked tumor necrosis.
    • The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-). The results are in favor of metastatic adenocarcinoma from colorectal origin. Please correlate with the clinical presentation and image study.
  • 2023-03-07 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2023-03-07 CT - chest
    • Indication: lung ca
    • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: a large tumor lesion (60 mm in longest dimension, polylobular borders) over lingula.
        • numerous randomly distributed pulmonary nodules/masses of varying sizes in both lungs due to metastases.
        • centrilobular nodular and branching opacities at LUL.
      • Mediastinum and hila: enlarged LNs in the visceral space and left anterior prevascular space and Lt hilum
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and concentric LVH. mild calcified mitral annulus
      • Pleura: small Rt-sided effusion with thickening.
      • Chest wall and visible lower neck: infiltrative soft-tissue mass at Rt middle posterior chest wall with destruction pof 8th rib and adjacent vertebra.
      • Visible abdominal contents: mild dilatation of CHD and CBD as well as Lt IHDs.
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
        • bilateral commonl iliac arteries.
    • Impression:
      • lingula ca T4N3M1a
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2023-03-05 CXR
    • Presence of multiple lung nodules/masses.

[consultation]

  • 2023-03-29 Radiation Oncology
    • Q
      • This 71-year-old man patient is a case of T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. Lower back pain developed with whole body bone scan on 2023/03/07 showede skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus multiple bone metastases. Now, for evaluate palliative radiotherapy to bone metastasis of pain control. Thank you.
    • A
      • Palliative RT is indicated. CT-simulation will be arranged on 20230406, or earlier if there is an earlier vacancy.
      • Plan to deliver 30 Gy/ 10 fx to the L-spine and pelvic bone mets. Thank you very much.

[SOAP]

  • 2023-04-02 Emergency
    • S: the patient started to diarrhea for 1 week (5 to 6 times per day) just after discharged on 20230401.
    • prescription: Smecta (dioctahedral smectite) 3mg/pk PRNQ8H for 3 days
  • 2023-03-23 Hemato-Oncology
    • O: Will on FOLFIRI with or without targeted therapy
    • P: Admission for Pelvis MRI, T spine MRI and L-S MRI and Consult RTO, Consult CS or Port-A. Then FOLFOX

[radiotherapy]

[chemotherapy]

  • 2023-04-14 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg IVD + aprepitant 125mg PO D1-3
  • 2023-03-29 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

2023-04-17

[assessment]

  • The patient experienced diarrhea (5 to 6 times per day) immediately after discharge on 2023-04-01. Both Smecta (dioctahedral smectite) and Through (sennoside) are currently prescribed. It is suggested to confirm the patient’s bowel movement status and determine if both medications are necessary.
  • Irinotecan was increased from 120 mg to 150 mg/m2 in this second dose of the FOLFIRI regimen.
  • Hypokalemia (2.9 mmol/L) was noted on 2023-04-14 and is currently being treated with oral potassium chloride supplementation.
  • Anemia was noted prior to the patient’s first dose of FOLFIRI on 2023-03-29. A packed red blood cell (P-RBC) transfusion of 2 units was performed on 2023-04-14.
    • 2023-04-14 HGB 8.0 g/dL
    • 2023-04-02 HGB 8.9 g/dL
    • 2023-03-23 HGB 9.6 g/dL
  • There is no medication reconciliation issue with the active prescription.

2023-03-29

[assessment]

  • The patient is a senior with T-colon cancer, partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. He admitted for his first cycle of FOLFIRI with a 2/3 dose of irinotecan (this time 120mg/m2, standard 180mg/m2).
  • Lab results on 2023-03-23 revealed a WBC count of 17K/uL, but no CRP or procalcitonin data were available. Please rule out any infectious symptoms.
  • The patient has a history of uncontrolled hypertension for 10 years, which requires further follow-up.

701473874

230414

[diagnosis] - 2023-04-07 admission note

  • Pancreatic head cancer with gastric and common bile duct involvement with gastric outlet obstruction and liver metastasis , cT4N1M1 stage IV; status post Roux-en-Y hepatico-Jejunosotmy and gastro-Jejunosotmy bypass and cholecsytectomy on 2023/03/27. ECOG:1
  • Encounter for adjustment and management of vascular access device with port-A insertion on 2023/04/06
  • Pancreatic head tumor with gastric and common bile duct involvement with gastric outlet obstruction and obstructive jaundice status post Percutaneous Transhepatic Cholangial Drainage on 2023/03/11
  • Hypokalemia
  • Rheumatoid arthritis history

[exam findings]

  • 2023-04-12 KUB
    • known s/p Roux-en-Y hepatico-Jejunosotmy and gastro-jejunostomy bypass and cholecsytectomy.
    • increased air in nondistended loops of small bowel over lower abdomen and pelvic
  • 2023-03-27 Patho - gallbladder (benign lesion)
    • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis
  • 2023-03-16 Patho - pancreas biopsy
    • Labeled as “stomach pyloric wall thickening”, fine needle biopsy (B) — adenocarcinoma.
    • IHC stains: CK 19 (+), CA19-9 (+), CDX-2 (+), CK7 (+), CK20 (-). in favor of pancreato-biliary origin.
  • 2023-03-15 Endoscopic Ultrasonography, EUS
    • susp. Pancreatic IPMN main duct type s/p EUS/FNB (A)
    • Prob. gastric pyloric invasion s/p FNB (B)
    • pancreatic cystic neoplasm, tail susp. MCN type
    • Ascites, minimal
    • lymphadenopathy
  • 2023-03-10 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider inferior ischemia
    • T wave abnormality, consider anterolateral ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2023-03-10 CT - abdomen
    • CC:
      • Mild epigastralgia for 4 days, took medication for ulcer but jaundice noted 2 weeks, Tea color urine, clay color stool, Skin itching
      • No significant poor appetite. mild weight loss.
      • on diet, Alcohol (-) smoking (+). family hepatitis B or C history but she receive hepatitis B vaccination before.
      • PH. RA
    • Occupation: Mount Temple Services
    • Indication: biliary obstruction related jaundice was suspected.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is marked dilatation of IHDs and CHD, but small size of the gallbladder.
        • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
        • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
      • There is symmetrical wall thickening at the gastric antrum, causing marked distension of the proximal stomach that is c/w gastric outlet obstruction.
        • The differential diagnosis includes adenocarcinoma and old ulcer with deformity. Please correlate with gastroscopy.
        • In addition, there is a cystic lesion in the dorsal aspect of the stomach fundus that may be duplication cyst.
      • Several cystic lesions in the pancreatic body and tail are suspected.
        • The differential diagnosis includes pancreatic duct dilatation.
        • Please correlate with MRCP.
      • Others
        • There is no focal abnormality in the spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
        • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
        • Please correlate with tumor marker, MRCP and ERCP.
      • Stomach cancer at the antrum is highly suspected.
        • Please correlate with gastroscopy.
  • 2023-03-11 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
    • Dilatation of the biliary tree (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • 2023-03-10 Esophagogastroduodenoscopy, EGD
    • c/w tumor compression or invasion, posterior wall of antrum
    • Gastric outlet obstruction
    • duodenal ulcer, bulb
    • Possible ulcer at posterior wall of bulb or antrum
  • 2023-03-07 SONO - abdomen
    • Diagnosis
      • Suspect distal CBD tumor with biliary tract obstruction
      • Suspect pancresatic body tumor
      • Intra-abdominal cystic lesion, LUQ area
      • Gastric outlet obstruction
    • Suggestion
      • CT and EGD study.

[SOAP]

  • 2023-04-12 Hemato-Oncology
    • Refer to ER for treating BTI (Biliary Tract Infection) and then admission -> consider Abraxane (paclitaxel) plus gemcitabine (see [note] section) after infection under control

[surgical operation]

  • 2023-03-27
    • Surgery
      • Roux-en-Y hepatico-Jejunosotmy
      • GJbypass
      • cholecsytectomy
    • Finding
      • pancreatic head cancer invasion to pyloric and hepatico-duodunostomt
      • LLS liver mets with gastric anerior wall invasion

[note]

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

  • Cycle length: 4 weeks.
  • Regimen
    • Nabpaclitaxel
      • 125 mg/m2 IV
      • Administer undiluted over 30 minutes.
      • Days 1, 8, and 15
    • Gemcitabine
      • 1000 mg/m2 IV
      • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
      • Days 1, 8, and 15

Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

  • Adjuvant setting
    • Adjuvant gemcitabine
    • Adjuvant gemcitabine plus capecitabine
    • Modified FOLFIRINOX
  • Locally advanced/metastatic disease
    • Gemcitabine monotherapy
    • Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) (see above for components)
    • Gemcitabine plus capecitabine
    • Gemcitabine plus cisplatin
    • FOLFIRINOX (fluorouracil plus leucovorin, irinotecan, and oxaliplatin)
    • Modified FOLFIRINOX
    • Modified FOLFOX6 (fluorouracil plus leucovorin and oxaliplatin)
    • Liposomal irinotecan and 5-FU for metastatic pancreatic cancer
    • Pembrolizumab monotherapy for microsatellite-unstable (mismatch repair-deficient) advanced cancer

[assessment]

  • Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.

  • It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.

  • No medication reconciliation issues were noted for the patient.

700553084

230413

{not completed}

[past history]

  • Myelofibrosis grade 1-2 disease in March 2020 with Bokey treatment.
  • Hypertension with Norvasc since 2023/03/24 due to headache with neck soreness.

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-13, -04-10, -04-06, -04-03, -04-01 CXR
    • hazy areas of increased opacity and reticular opacities with poor defination of vessels over Rt and Lt lungs
  • 2023-04-06 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — compatible with essential thrombocythemia with grade 3 myelofibrosis.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are increased in number.
    • IHC stains: CD117: <2%; CD34: <2 %; MPO:50 %, CD61: 25 %; CD71: 25% (of the nucleated cells).
    • Reticulin stain: marked increased amounts of reticulin.
    • Masson-Trichrome stain: marked increased in the amounts of collage fibers.
  • 2023-03-30 Bronchoscopy
    • Trachea: mid- and lower-1/3 segments was patent and the mucosa was swelling.
    • Main carina: sharp and movable on deep breathing.
    • Right bronchial trees: swelling and easy touch bleeding with dynamic collapse of lower bronchial orifices
    • Left bronchial trees:mucosa swelling and touch bleeding was found.
  • 2023-03-29 CXR
    • Enlargement of cardiac silhouette.
    • Linear infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-28 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
  • 2022-03-31 SONO
    • Findings
      • Increased echogenicity of the liver.
      • Normal appearance of gallbladder without stone.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/ bowel gas.
      • Splenomegaly.
      • No evidence of pleural effusion.
      • Normal appearance of kidneys.
    • IMP:
      • Mild fatty liver.
      • Splenomegaly
  • 2020-03-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, history of myeloproliferative neoplasm, JAK2 (+), biopsy — see microscopic description.
    • IHC stains: CD117: <1%, CD34: <1%, MPO: 20-30%, CD61: 30-40%, CD71: 30-40%.
    • Reticulin stain: mild to moderately increased reticulin fibers;
    • Mason-Trichrome stain: mild increase in collagen fibers.
  • 2019-02-12 SONO - spleen
    • Sonography of spleen revealed splenomegaly without nodule.
  • 2017-08-10 SONO - abdomen
    • marked splenomegaly

[SOAP]

  • 2023-02-24 Hemato-Oncology
    • Bokey (aspirin 100mg) QD
  • 2022-09-23 Hemato-Oncology
    • Suggest bone marrow study
    • OPD follow up x 2 months
  • 2022-03-23 Hemato-Oncology
    • Neoplasm of uncertain behavior of polycythemia vera [D45]
    • Hepatitis, unspecified [K75.2]
    • IWG-MRT score 1 (intermediate-1)
    • IPSS: 1. anti-JAK2 inhibitor is not reimbursed by NHI (will be paid on 2 or higher) (202003324).
    • A: MPN wtih myelofibrosis
    • recheck abdominal sonogram
  • 2021-10-05 Hemato-Oncology
    • A
      • Neoplasm of uncertain behavior of polycythemia vera [D45]
      • Hepatitis, unspecified [K75.2]
  • 2017-01-19 Hemato-Oncology
    • O
      • Marked splenomegaly.
      • JAK2 mutation: present.
      • A: Myeloproliferative neoplasms, MPN
    • A
      • Neoplasm of uncertain behavior of polycythemia vera [D45]
      • Essential hypertention, unspecified [I10]
      • Hepatitis, unspecified [K75.2]
      • Gouty arthropathy [M10.00]

[assessment]

  • Triazole antifungal agents include voriconazole, posaconazole, itraconazole, and fluconazole. Fluconazole has no activity against Aspergillus spp, and itraconazole has become a second-line agent for aspergillosis. Voriconazole should be included in the antifungal regimen in most patients with invasive aspergillosis

701244841

230413

[diagnosis] - 2023-03-24 admission note

  • Malignant neoplasm of duodenum
  • Acute duodenal ulcer without hemorrhage or perforation
  • Calculus of gallbladder with chronic cholecystitis without obstruction
  • Noninfective gastroenteritis and colitis, unspecified
  • Benign neoplasm of duodenum

[past history]

Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA

Surgery history: - C-spine compression fracture s/p over 10 years ago    

[allergy]

  • NKDA     

[family history]

Father: Liver cancer

[lab data]

  • 2023-03-15 Anti-HBc Reactive
  • 2023-03-15 Anti-HBc-Value 7.62 S/CO
  • 2023-03-15 Anti-HBs 0.30 mIU/mL
  • 2023-03-15 Anti-HCV Nonreactive
  • 2023-03-15 Anti-HCV Value 0.26 S/CO
  • 2023-03-15 HBsAg Reactive
  • 2023-03-15 HBsAg (Value) 125.62 S/CO
  • 2022-12-13 RPR/VDRL Reactive-1:2
    • ChatGPT: RPR (Rapid Plasma Reagin) and VDRL (Venereal Disease Research Laboratory) are blood tests used to screen for syphilis, a sexually transmitted infection caused by the bacterium Treponema pallidum. In this context, “reactive 1:2” means that the test has detected the presence of antibodies against syphilis in the blood at a dilution of 1:2, indicating a low level of infection. However, further confirmatory testing is necessary to determine if the individual has an active syphilis infection or if the antibodies detected are from a past infection that has been successfully treated.
  • 2022-10-20 RPR/VDRL(CSF) Non-Reactive
  • 2022-10-06 TPHA Reactive,1:640
    • ChatGPT: A TPHA (Treponema Pallidum Hemagglutination) result of 1:640 is a high titer and indicates a strong reaction to Treponema pallidum, the bacterium that causes syphilis. This can indicate an active syphilis infection, a previous infection that has been treated, or a false positive result. Further testing and evaluation by a healthcare provider is necessary to determine the significance of the result and whether treatment is needed.
  • 2022-09-15 RPR/VDRL Reactive-1:4
    • ChatGPT: A reactive RPR/VDRL result of 1:4 indicates a higher level of antibodies against syphilis in the blood compared to a result of 1:2. A higher titer result generally indicates a more active infection, but it can also indicate a past infection that has been successfully treated. Further testing and clinical evaluation are needed to determine the stage and treatment of syphilis.

[exam findings]

  • 2023-03-22 Clinical Dementia Rating
    • CDR score: 2
  • 2023-03-22 Mini-Mental State Examination
    • MMSE score: 16
  • 2023-03-14 EEG
    • This EEG study recorded background continuous diffuse theta rhythm (6-7 Hz) and plenty beta activity with occasional frontal slow waves.
    • No epileptiform discharge.
    • This EEG study suggested mild cortical dysfunction.
    • Please correlate with clinical features.
  • 2023-02-17 Patho - small intestine resection for tumor
    • Diagnosis
      • Small intestine, duodenum, second portion, pancreatico-duodenectomy — Adenocarcinoma, moderately differentiated, s/p subtotal gastrectomy with B-II anastomosis
      • Pancreas, head, pancreatico-duodenectomy — Adenocarcinoma, by direct invasion
      • Common bile duct, pancreatico-duodenectomy — Negative for malignancy
      • Lymph node, peri-pancreatic and mesentery, dissection — Adenocarcinoma, metastatic (2/17)
      • Gallbladder, cholecystectomy — Negative for malignancy
      • Lymph node, retroperitoneal, dissection — Negative for malignancy (0/3)
      • AJCC 8th edition: pStage IIIA, pT4N1(if cM0)
    • Gross Description:
      • Specimen Type: pancreatico-duodenectomy and cholecystectomy; s/p subtotal gastrectomy with B-II anastomosis
      • Specimen and size:
        • Head of pancreas: 4.5 x 4.0 x 2.7 cm, the pancreatic duct is dilated
        • Duodenum: 17.0 cm in lenghth
        • Stomach: not received
        • Common bile duct: 6.0 cm in length and 0.8 cm in diameter
        • Gallbladder: 9.2 x 3.8 x 2.0 cm
      • Tumor Site: Duodenum
      • Tumor Size: 5.5 x 5.0 x 4.4 cm with invasion to pancreatic head
      • Sections are taken and labeled as: A1: CBD resection margin; A2-3: pancreatic and soft tissue resection margin; A4: distal duodenal resection margin; A5: blind end margin; A6: peritoneal resection margin; A7: superior soft tissue resection margin; A8: inferior soft tissue resection margin; A9: ampulla Vater, CBD and tumor; A10: panreatic dyct; A11-15: tumor; A16-17: lymph node, peripancreatic and mesentery; B: gallbladder; C: lymph node, retroperitoneal.
    • Microscopic Description:
      • Histologic Type: adenocarcinoma
      • Histologic Grade (applies to ductal carcinoma only): G2: Moderately differentiated
      • Tumor Extension: invasion to pancreatic head and retroperitoneal soft tissue
      • Margins
        • All margins are uninvolved by invasive carcinoma,
        • Distance of invasive carcinoma from closest margin: 12 mm.
        • Specify: retroperitoneal soft tissue resection margin
        • Blid end resection margin: 1.5 cm
        • distal duodenum resection margin: 12.2 cm
        • CBD resection margin: 3.0 cm
        • Pancreatic resection margin: 1.5 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Regional Lymph Nodes: peri-pancreatic and mesentery: 2/17; retroperitoneal: 0/3
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable): not applicable
          • Primary Tumor (pT): pT4: invasion of pancreas
          • Regional Lymph Nodes (pN): pN1: Metastasis in one to two regional lymph nodes
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings: The pancreatic parenchyma reveals atrophy. The pancreatic duct is dilated with low grade pancreatic intraepithelial neoplasia.
  • 2023-02-11 MRI - upper abdomen
    • History and indication: Duodenal cancer before surgery
    • With and without contrast MRI of upper abdomen revealed:
      • Motion artifact.
      • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
      • S/P gastric operation.
      • Distention of gallbladder.
    • IMP:
      • Motion artifact.
      • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
      • Distention of gallbladder.
  • 2023-02-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 21.7) / 81.3 = 73.31%
      • M-mode (Teichholz) = 73.3
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2023-02-07 Flow Volume Loop
    • poor performance
    • the family expressed that the patient is physically weak and therefore unable to blow air.
  • 2023-02-06 ECG
    • Atrial fibrillation with slow ventricular response
    • Low voltage QRS
    • Left anterior fascicular block
  • 2023-12-30 Patho - doudenum biopsy
    • Labeled as “duodenum, second portion”, biopsy — adenocarcinoma.
    • Section shows piece of duodenal tissue with dysplastic and neoplastic glands.
    • IHC stains: CK 19 (+), CK7 (+), CK20 (focal +), CD56 (-), Ki-67: 90%.
  • 2022-12-27 CT - abdomen
    • History and indication: Abdominal pain
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Pectus excavatum.
      • S/P gastric operation ?
      • Wall thickening of duodenum, 2nd portion, r/o malignancy.
      • Distention of gallbladder. Dilatation of p-duct.
    • IMP:
      • Wall thickening of duodenum, 2nd portion, suspected malignancy.
      • Distention of gallbladder.
      • Dilatation of p-duct.

[consultation]

  • 2023-02-08 Anesthesiology
    • Q
      • This is 72-year-old man with past history of C-spine s/p OP, CAD, Syphilis infection s/p Penicillin IVD x3 on 2022/10-11 (Treatment finished, 2022/12 RPR: reactive [1:2]), Alzheimer’s disease and Gout. The patient was diagnosed duedenal cancer at the end of 2022, and he admitted for operation.
      • The patient was only 50 kg with poor nutrition in recent several months, so we needed TPN to supply the nutrition for him before surgery. He was also TPN supportive care after surgery.
      • The patient had Syphilis infection, and the patient worried about the CVC insertion. We would like to consult your expertise for CVC insertion.
    • A
      • We were consulted for CVC insertion due to peripherally incompatible infusions .
      • The 3-way CVC was inserted into right IJV, fixed at 15 cm, under sonography guidance smoothly.
      • Please arrange portable CXR for CVC position examination.
      • CXR revealed proper position of the CVC.
  • 2022-10-19 Metabolism and Endocrinology
    • Q
      • This 71 y/o man has a history of CAD and C-spine s/p. He visited neurology OPD recently for cognitive decline. Laboratory survey showed syphilis infection and hypothyroidism.
      • We need your expertise for hypothyroidism evaluation and management. Thank you very much.
    • A
      • S
        • This 71-year-old male, with past history of CAD and C-spine s/p, was admitted due to cognitive decline, susp. neurosyphilis or hypothyroidism related. We were consulted for abnormal TFT.
      • O:
        • BW: 49
        • HR: 50-68
        • Possible related medication: nil
        • ALT: 15
        • Cr: 0.95
        • Na/K: unavailable
        • TSH/FT4 (nuclear medicine): 18.697/0.748
        • T3: unavailable
        • ATPO: 3.2, ATG: < 0.9
        • ACTH/Cortisol (random, 3-4pm): ?/8.17
        • Thyroid sono: nil
        • ECG: nil
      • A: Primary hypothyroidism
      • Suggestions:
        • Add on thyroxine 50 mcg, 0.5 tablet, QDAC (please take at least 30 minutes before the first meal of the day), and monitor blood pressure, heart rate, electrolytes, and any cardiovascular complications.
        • Recheck TSH/FT4 (routine biochemistry) in 2 weeks (can be done as outpatient if discharged).
        • Arrange for thyroid sonography (radiology) and ECG for bradycardia.
        • Contact us if necessary. Follow-up with the Endocrine Outpatient Department.

[surigcal operation]

  • 2023-02-16
    • Surgery
      • pancreatico-duodenectomy with retroperitoneal LN dissection
    • Finding
      • 7.5 x 6 x 4 cm fungating mass was noted at duoenal 2nd portal with pancreastic head invasion
      • no peritoneal seeding was noted
      • previous subtotal gastrectomy with B-II anastomosis

[chemotherapy]

  • 2023-04-12 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Oxa 65mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-24 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Hold Oxalip due to old age and performance status)
    • dexamethasone 4mg + NS 250mL

==========

2023-04-13

  • The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.

  • For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.

  • There is no medication reconciliation issue found.

2023-03-27

  • The patient has been exposed to the hepatitis B virus (HBV) at some point in his life, Baraclude (entecavir) is properly prescribed.
    • 2023-03-15 Anti-HBc Reactive
  • A decrease in RPR/VDRL titer from 1:4 to 1:2 may indicate a treatment response to syphilis (Penicillin IVD x3 on 2022/10-11).
    • 2022-12-13 RPR/VDRL Reactive-1:2
    • 2022-09-15 RPR/VDRL Reactive-1:4
  • High levels of thyroid-stimulating hormone (TSH) and normal levels of free thyroxine (T4) may indicate subclinical hypothyroidism. Subclinical hypothyroidism may not cause any symptoms, but it can increase the risk of developing overt hypothyroidism in the future. It can also increase the risk of heart disease. It is recommended to monitor the levels of TSH and T4 further evaluation and management if necessary.
    • 2022-09-19 TSH (nuclear medicine) 18.697 uIU/ml
    • 2022-09-19 Free T4 (nuclear medicine) 0.748 ng/dl
  • On 2023-02-16, the patient underwent a pancreatico-duodenectomy with retroperitoneal lymph node dissection, and started receiving 5-fluorouracil (5FU) infusion on 2023-03-24. It is important to monitor the patient closely for any signs of gastrointestinal adverse reactions, as 5FU infusion may cause such symptoms. Additionally, given the patient’s history of CAD, it is also important to keep a close eye for any potential cardiovascular adverse reactions.

700537283

230412

[exam findings]

  • 2023-04-10 CXR
    • Few nodular opacities projecting in the left middle lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • S/P clips projecting at right lower medial lung.
  • 2023-02-16 CT (at SYKCC)
    • bil. breast masses
    • skin nodularities
    • bil. supraclavicular, Lt axillary and upper mediastinal lymphadenopathy.
    • liver and lung metasis

[SOAP]

  • 2023-03-30 Hemato-Oncology
    • S
      • History of breast ca before but it recurred in Sep 2021 but she did not seek formal medical attentison. She received biopsy at SYKCC where ER positive, PR (+), Her-2 (3) when multiple tumor over Rt chest wall. Double target therapy was done on 2023-03-07.
      • Swelling over port-A site (infected) (20230330)
      • She came for subsequent treatment.
    • O
      • Reason for not informing patient of her condition: Currently not suitable to inform.

[chemoimmunotherapy]

  • 2023-04-11 - docetaxel 35mg/m2 47mg NS 100mL 1hr (docetaxel + herceptin + perjeta)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

700626863

230412

[exam findings]

  • 2023-03-20 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — hypercellularity.
    • Section shows piece(s) of bone marrow with 50-60% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with left of leukocytes. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 30-40%; CD34: 30-40 %; MPO: 50-55 %, CD61: 5 %; CD71: 30-35 % (of the nucleated cells). Acute myelogenous leukemia may be considered.

[POMR]

  • 2023-04-10 Hemato-Oncology
    • Problem: Acute myeloblastic leukemia, FLT3 and NPM1 Undetectable, 46,XX,t(16;21)(p11.2;q22)[20] karyotype
      • Assessment: Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
      • Plan
        • Insertion on 2023/03/30
        • Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
        • Prophylasix antibiotics with Cravit po from 2023/03/31(D11) and antifungas with Fluconazole 2 tab QD from 2023/03/31(D11)
        • Adequate hydration with N/S 1500ml QD
        • Followed up laboratory test regularly  

[SOAP]

  • 2023-03-18 Medical Emergency
    • Menorrhagia for 2 weeks.
    • 2023/03/18 17:24 Blast = 9.8 %;
    • 2023/03/17 17:29 Blast = 5.9 %;
    • preliminary impression: D61.818 Other pancytopenia
      • Pancytopenia, Hb 7.2 to 6.1 to 6.8, blast 5.9% to 9.8%, OA ONC
  • 2023-03-17 Hemato-Oncology
    • 33 y female, PH: IDA (iron deficiency anemia)
    • Abnormal hemogram was informed at Taipei Mackey Hospital
    • recheck here: WBC 2540, Hb 6.1, Plt 116k, balst 5.9%
    • Imp: R/O leukemia

[chemotherapy]

  • 2023-03-31 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 156mg NS 500mL 24hr D1-7 (3+7 daunorubicin/cytarabine Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2

Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults

  • 7+3 therapy (cytarabine plus anthracycline)
    • The preferred approach for remission induction is a 7-day continuous infusion of cytarabine and anthracycline treatment on days 1 to 3, which is commonly referred to as “7+3 therapy.”
    • For medically fit patients, we suggest treatment as follows:
      • Cytarabine 100 to 200 mg/m2 daily as a continuous infusion for 7 days
      • Daunorubicin 60 to 90 mg/m2 on days 1 to 3 or idarubicin 12 mg/m2 on days 1 to 3
    • Treatment with 7+3 therapy generally achieves a complete remission (CR) rate of 60 to 80 percent for patients <60 to 65 years old. Long-term outcomes are influenced by cytogenetic/molecular features (the following table) and post-remission management.
      • 2017 European LeukemiaNet risk stratification of acute myeloid leukemia by genetics
        • Risk category: Favorable
          • Genetic abnormality
            • t(8;21)(q22;q22.1); RUNX1-RUNX1T1
            • inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11
            • Mutated NPM1 without FLT3-ITD or with FLT3-ITDlow
            • Biallelic mutated CEBPA
        • Risk category: Intermediate
          • Genetic abnormality
            • Mutated NPM1 and FLT3-ITDhigh
            • Wild type NPM1 without FLT3-ITD or with FLT3-ITDlow (without adverse-risk genetic lesions)
            • t(9;11)(p21.3;q23.3); MLLT3-KMT2A
            • Cytogenetic abnormalities not classified as favorable or adverse
        • Risk category: Adverse
          • Genetic abnormality
            • t(6;9)(p23;q34.1); DEK-NUP214
            • t(v;11q23.3); KMT2A rearranged
            • t(9;22)(q34.1;q11.2); BCR-ABL1
            • inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2,MECOM(EVI1) –5 or del(5q); –7; –17/abn(17p)
            • Complex karyotype, monosomal karyotype
            • Wild type NPM1 and FLT3-ITDhigh
            • Mutated RUNX1
            • Mutated ASXL1
            • Mutated TP53
    • Patients require aggressive intravenous hydration; monitoring for cardiac, renal, and liver dysfunction; blood product support; and surveillance for infections. Treatment with 7+3 therapy generally causes three to five weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. Many patients will experience nausea and vomiting, mucositis/stomatitis, alopecia, and diarrhea. Cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
    • Bone marrow examination should be performed 14 to 21 days after initiation of therapy to assess the initial response to therapy and determine whether a second induction course is needed.
    • Approximately four to five weeks after the start of therapy, when sufficient time has passed for recovery of normal blood counts, another bone marrow examination is performed to determine whether the patient has achieved remission.
    • Broadly, findings from randomized trials that examined the dose, schedule, and choice of agents have found that outcomes are similar between daunorubicin and idarubicin; higher dose daunorubicin (ie, 60 or 90 mg/m2/d) is more efficacious but not more toxic than lower dose (ie, 45 mg/m2/d) daunorubicin; and, compared with infusional cytarabine, high dose cytarabine (HiDAC) is associated with increased toxicity without an improvement in efficacy.

==========

2023-04-12

[follow up]

  • Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.

    • 2023-04-12 WBC 0.21 x10^3/uL
    • 2023-04-09 WBC 0.42 x10^3/uL
    • 2023-04-12 Neutrophil 5.8 %
    • 2023-04-09 Neutrophil 16.5 %
    • 2023-04-12 PLT 37 *10^3/uL
    • 2023-04-09 PLT 47 *10^3/uL
  • No fever in the past 7 days.

  • Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.

    • 2023-04-05 Blast 1.0 %
    • 2023-04-03 Blast 1.3 %
    • 2023-04-02 Blast 7.0 %
    • 2023-04-01 Blast 22.9 %
    • 2023-03-31 Blast 23.0 %
    • 2023-03-28 Blast 12.0 %
    • 2023-03-24 Blast 7.0 %
    • 2023-03-22 Blast 29.0 %
    • 2023-03-21 Blast 17.6 %
    • 2023-03-20 Blast 4.0 %
    • 2023-03-18 Blast 9.8 %
    • 2023-03-17 Blast 5.9 %

2023-04-10

  • The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.

    • 2023-04-09 WBC 0.42 x10^3/uL
    • 2023-04-07 WBC 0.92 x10^3/uL
    • 2023-04-05 WBC 1.43 x10^3/uL
    • 2023-04-03 WBC 1.78 x10^3/uL
    • 2023-04-02 WBC 2.64 x10^3/uL
    • 2023-04-01 WBC 3.31 x10^3/uL
    • 2023-03-31 WBC 3.63 x10^3/uL
    • 2023-03-28 WBC 4.49 x10^3/uL
    • 2023-04-09 Neutrophil 16.5 %
    • 2023-04-07 Neutrophil 55.0 %
    • 2023-04-05 Neutrophil 64.0 %
    • 2023-04-03 Neutrophil 39.9 %
    • 2023-04-02 Neutrophil 75.3 %
    • 2023-04-01 Neutrophil 60.0 %
    • 2023-03-31 Neutrophil 33.0 %
    • 2023-03-28 Neutrophil 50.0 %
  • Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.

  • It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.

  • Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:

    • Hypoplastic: Bone marrow cellularity <5 to 20 percent and <5 percent blasts
    • Indeterminate: Bone marrow cellularity <5 to 20 percent with >=5 percent blasts
    • Persistent leukemia: Some clearing of leukemia or no response, but cellularity >=20 percent
  • Institutions vary in their responses to findings of the day 14 bone marrow examination.

    • For some centers, all medically-fit patients receive a second cycle of the same induction therapy, but those with persistent disease may receive more intensive/alternate treatment (eg, high dose cytarabine [HiDAC] plus mitoxantrone; mitoxantrone, etoposide, and cytarabine [MEC], other regimen.)
    • Other centers use the following approach, guided on the day 14 marrow results:
      • Hypoplastic: Observation for two to four weeks until recovery of blood counts. If pancytopenia persists, then repeat bone marrow biopsy.
      • Indeterminate: Repeat the bone marrow examination one to two weeks later, with subsequent management guided by whether the repeat study demonstrates hypoplasia versus persistent leukemia.
      • Persistent leukemia: Repeat treatment with the regimen, or treat with a more intensive or alternate induction therapy (eg, HiDAC-based therapy, hypomethylating agent plus venetoclax, other regimen).
  • Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.

700040129

230411

{not completed}

[exam findings]

  • 2023-04-11 MRI - brain
    • Indication: Right upper lobe lung cancer with mediastinal lymphadenopathy, lung, liver and bone metastasis, cT3N2M1c, stage IVB
    • Findings
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
      • C2 and right C3 metastases/bone destructions.
      • Abnormal enhancement after contrast administration of C2-3 bodies were noted.
    • Imp:
      • No brain or skull metastases.
      • C2 and right C3 metastases.
  • 2023-04-11 Bronchoscopy
    • Endo-bronchial tumor with partial obstruction at RB3, s/p Cryobiopsy
  • 2023-04-07 CT - chest
    • Indication: multiple bone metastasis - from chest to pelvis please,
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated mass at right upper lobe measuring 3.8cm in largest dimension is found.
        • Lymphadenopathy at right hilar and paratracheal region is found.
        • Mild bilateral pleural effusion is found.
        • One nodular lesion at right lower lobe measuring 0.85cm is found. suspected lung meta.
      • Visible abdomen:
        • Low density lesions are found at both lobes of liver are found. Liver meta is considered.
        • Diffuse wall thickening of the ascending colon is found. suspeted colitis.
        • The urinary bladder is well distended without soft tissue lesion.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Right upper lobe lung cancer with mediastinal lymphadenopathy, lung meta and liver meta, bone meta. T3N2M1c.
  • 2023-04-03 CXR
    • Lung markings: a nodular lesion, about 32mm, in the right upper lung field
  • 2023-04-03 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-04-03 MRI - c-spine
    • IMP
      • mild retrolisthesis at C4-5 and C5-6
      • r/o multiple bone metastasis with pathological fracture at C2 vertebral body. PLease correlate with contrast-enhanced study.
  • 2023-03-31 C-spine AP & Lat
    • Loss of normal lordotic alignment
    • Disc space narrowing and posterior spur at C4-5-6
  • 2023-03-14 C-spine flex & ext view
    • mild angulation at the middle C-spine
    • mild anterior and posterior spur formation at the middle and lower C-spine
    • moderate decreased disc spaces in the C4/5 and C5/6 discs

[consultation]

  • 2023-04-03 Neurology
    • Q
      • posterior neck pain for a week, no arms numb nor weak.
      • c spine on 20230331:
        • Loss of normal lordotic alignment
        • Disc space narrowing and posterior spur at C4-5-6
    • A
      • S: complained of severe neck pain while axial loading (relieved by lying down)
      • O
        • E4V5M6
        • pupil: 3+/3+
        • MP full
        • no limbs paresthesia
        • MRI: suspected multiple bone metastasis with pathological fracture at C2 vertebral body
      • P
        • since there’s no MP weakness, limbs numbness, no operation is indicated now
        • suggest oncologist consultation and tumor survey

700882997

230411

{not completed}

[exam findings]

  • 2023-04-03 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Mild plasmacytosis and see description
    • The sections show normocellular marrow (30%). The erythoid precursors are decreased, dispersed, and scattered in CD71 stain. The myeloid cells show good maturation. The CD61+ megakaryocytes are normal in number and morphology. Increased CD138+ mature plasma cells, account for 15% of marrow cells without lambda or kappa light chains restriction. No CD34+ blasts can be found. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-03-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-10 Patho - colon biopsy
    • Colorectum, ascending colon, s/p biopsy near total removal (A) — Hyperplastic polyp
    • Colorectum, transverse colon, s/p biopsy removal (B) — Hyperplastic polyp
    • Colorectum, descending colon, s/p biopsy removal (C) — Hyperplastic polyp
    • Colorectum, rectum, s/p biopsy removal (D) — Hyperplastic polyp
    • Colorectum, rectum, 5 cm above anal verge, biopsy (E) — Hyperplastic polyp
  • 2023-03-08 Patho - doudenum biopsy
    • Duodenum, bulb to second portion, biopsy — mild to moderate lymphocytic infiltration.
    • Section shows piece(s) of bland duodenal tissue with mild to moderate lymphocytic infiltration.
    • IHC stains: CD3 and CD20: no predominant sub-population, in favor of chronic inflammation.
  • 2023-03-08 SONO - abdomen
    • Parenchymal liver disease
    • Cholecystopathy
    • Gallbladder polyp
    • Minimal ascites
    • Sus lymphadenopathy, beside panc body
  • 2023-03-06 CTA - chest
    • Indication: Fever, unspecified Dizziness and giddiness, Dyspnea, unspecified Anemia, unspecified
    • MDCT (80-detector rows,Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
      • Lungs: centrilobular emphysema in both upper lobes (moderate Lt, mild RT), and mild subpleural paraseptal emphysema in LUL. dependent linear band subsegmental atelectasis at lower lobes.
      • Mediastinum and hila:
      • Vessels: mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification of ascending
      • Heart: normal in size of cardiac chambers.
      • Pleura: mild bilateral effusions.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: hyperplasia of Lt adrenal gland
        • normal appearance of gall bladder. unremarkable of the liver, spleen, Rt adrenal gland, pancreas, and both kidneys. bile ducts: No dilatation.
        • no enlarged lymph node. no ascites.
        • Atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • emphysema in both upper lobes, most severe on Lt smoking related disease. small pleural effusion, transudate.
  • 2023-03-06 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-09-21 Pure Tone Audiometry
    • PTA Reliability FAIR
    • Average RE 30 dB HL; LE 35 dB HL.
    • R’t normal to moderately severe SNHL. (BC masking dilemma at 4k Hz)
    • L’t normal to moderately severe SNHL with ABG at 4k Hz.
  • 2022-03-09 ENT Hearing Test
    • Tymp:
      • R’t type Ad; L’t type A.
    • ART:
      • R’t absent.
      • L’t absent except ipsi 500 Hz.
    • PTA
      • Reliability FAIR
      • Average RE 21 dB HL; LE 26 dB HL.
      • R’t normal to moderate SNHL.
      • L’t normal to moderately severe SNHL.

[consultation]

  • 2023-03-13 Hemato-Oncology
    • Q
      • For anemia and thrombocytopenia
      • This 72-year-old male has past history of Hypertension and Af under medication control at West Garden Hospital. According to his statment, intermittent shortness of breath for 2 weeks ago, accompanied with productive cough, dizziness and bilateral hands tremor for 1 weeks. The symptom got worsen, thus he was brought to our ER for help. At ER, vital signs showed TPR: 35.6’C/121bpm/20; BP:125/60 mmHg. Con’s:E4V5M6. Laboratory data revealed normacytic anemia of Hb 7.8g/dL, elevated CRP (8.78 mg/dL), NTpro BNP (1018 pg/mL) and D-dimer (980.96 ng/mL). Chest CTA showed emphysema in both upper lobes. He denied abdomen pain, tarry stool or bloody stool. Urinalysis showed no pyuria. Denied TOCC history. Under the impression of pneumonia and suspect GI bleeding, he was admitted to our ward for further evaluation and treatment.
      • After admitted, he recevied IV fluid supplement, empirical antibiotic with unasym for infection control.
      • Stool transfirrin/FOB showed positive. EUS and colonscopy were performed for anemia survey, which showed duodenal ulcers and rectal polypoid lesions with ucer.
      • Anemia was correct with Hb > 9.0.
      • Follow laboratory data revealed thrombocytopenia (PLT 65000/uL -> 70000/uL -> 52000/uL -> 35000/uL). Abdomen echo showed no splenomegaly.
      • We need your expertise to evaluate for anemia and thrombocytopenia further evaluation, sincerely thanks.
    • A
      • This 72 year old man is a case of pneumonia. We are consulted for bicytopenia (normocytic anemia and thrombocytoepnia).
      • Pending endoscopy biopsy result. Please check RBC morphology, haptoglobin (done), total/direct bilirubin (done), ANA, RF, C3, C4, anti Ds DNA, AntiRo/La, IgG,IgA,IgM, total protein/albumin, serum EP, serum IFE, serum light chain, lupus anticoagulant, anti-cardiolipid IgM/IgG, anti B2 glycoprotein Ab, Ferritin (done), Fe/TIBC (done), B12 (done), folic acid(done) and tumor marker. Watch for any bleeding sign which may cause platelet consumption. If still unexplained cytopenia, bone marrow aspiration and biopsy is indicated.
      • Typical recommended platelet count thresholds used for some common procedures are listed below. Platelet transfusion may be considered when the patient platelet count is below the threshold for the corresponding procedure.
        • Neurosurgery or ocular surgery - <100,000/microL
        • Most other major surgery - <50,000/microL
        • Endoscopic procedures - <50,000/microL for therapeutic procedures; 20,000/microL for low risk diagnostic procedures
        • Bronchoscopy with bronchoalveolar lavage (BAL) - <20,000 to 30,000/microL
        • Central line placement - <20,000/microL
        • Lumbar puncture - <10,000 to 20,000/microL in patients with hematologic malignancies and <40,000 to 50,000 in patients without hematologic malignancies; lower thresholds may be used in patients with immune thrombocytopenia (ITP)
        • Neuraxial analgesia/anesthesia - <80,000/microL
        • Bone marrow aspiration/biopsy - <20,000/microL

[lab data]

2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive

701452959

230411

[diagnosis] - 2023-04-10 admission note

  • Malignant neoplasm of rectosigmoid junction
  • Adenocarcinoma of the rectum and sigmoid colon,T4N2bM1a, stage III
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension
  • Hyperlipidemia, unspecified

[past history]

  • diabetes mellitus for years under OHA & insulin control at SanChong LMD and hepatitis B.
  • Port-A was inserted on 2023-03-14.     

[allergy]

  • NKDA     

[family history]

  • Mother: breast cancer
  • Sister: lymphoma

[exam findings]

  • 2023-04-10 KUB
    • A renal stone in left lower pole is suspected.
    • Fecal material store in the colon.
    • Vas deferens calcification is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at right lateral aspect L4-5.
  • 2023-03-10 Whole body PET scan
    • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary rectosigmoid colon malignancy.
    • Mild glucose hypermetabolism in six regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • No prominent abnormal focal FDG uptake was noted in the liver and no prominent FDG uptake was noted in the left external iliac lymph node.
    • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-03-01 CT - abdomen
    • CC:
      • bowel habit change and anal discomfort + tenesmus recent times.
      • Constipation with excessive straining (unstable)
    • 20230224 colonoscopy: One circumferential tumor was noted at proximal rectum, 8-9cm above anal verge, s/p biopsy x6. The scope cannot pass through the lesion.
    • Past history: (DM + HTN)
    • Indication: suspect rectum lesion
    • Findings:
      • There is long segmental circumferential asymmetrical wall thickening with irregular contour at the rectum and sigmoid colon, measuring 12 cm in length that is c/w adenocarcinoma (T4a).
        • The fat plane between the sigmoid colon lesion and the urinary bladder shows equivocal obliteration. Please correlate with MRI to R/O urinary bladder invasion or attachment.
        • In addition, there are ten enlarged nodes in the pericolic area that are c/w metastatic nodes (N2b). IIIC
      • There is an ill-defined poor enhancing lesion 1 cm in S6/7 of the liver that may be cyst, pseudo-lesion, or metastasis?
        • Please correlate with MRI.
      • There is one enlarged node in left external iliac chain, measuring 6 mm in short axis (normal cut of value: 7mm) and fat density that may be reactive node.
        • The differential diagnosis includes non-regional metastatic node (M1a).
        • Please correlate with PET scan.
    • Impression:
      • Adenocarcinoma of the rectum and sigmoid colon.
        • Please correlate with MRI.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a or T4b, N2b, M1a?
        • Please correlate with Pelvis MRI and PET scan.
  • 2023-02-24 Patho - colon biopsy
    • PATHOLOGIC DIAGNOSIS
      • Proximal rectal tumor, 8-9 cm above anal verge, biopsy — Adenocarcinoma
      • Distal rectal polyp, biopsy removal — Tubular adenoma, low grade dysplasia
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of (A) three small pieces of tumor tissue measuring up to 0.3 x 0.2 x 0.1 cm in size and (B) four tiny pieces of polyp tissue measuring up to 0.2 x 0.2 x 0.1 cm in size respectively, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in cassette A: rectal tumor and B: sessile polyp.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show pictures as follows:
        • Proximal rectal tumor: adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia.
          • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor
        • Distal rectal polyp: tubular adenoma with low grade dysplasia
  • 2023-02-24 Colonoscopy
    • high suspected rectal cancer, s/p biopsy (A)
    • rectal polyp, s/p biopsy removal (B)
    • mixed hemorrhoid
  • 2022-10-11 Bladder Sonography
    • PVR: 71mL
  • 2022-09-28 Humerus RT
    • suspected fracture at the right proximal humeral bone.
  • 2022-09-27 Transrectal Ultrasound of Prostate, TRUS-P
    • CC:
      • small stream +
      • nocturia 5/N
    • PH:
      • DM(+), HTN(-), CAD(-), COPD(-), Asthma(-), CVA(-)
    • Surgical history: denied
    • Substance use: denied
    • Prostate:
      • Size of prostate: 4.76(T)cm x 2.59(L)cm x 5.12(AP)cm = 33.0cc
      • Size of adenoma: 3.14(T)cm x 2.25(L)cm x 2.97(AP)cm = 11.0cc
    • Seminal vesicles:
      • L
        • Size:L’t1.68 x 0.802 cm
        • Vas deferens:Normal
        • Cyst:No
        • Abscess:No
        • Tumor:No
      • R
      • Size:R’t1.55 x 1.34 cm
      • Vas deferens:Normal
      • Cyst:No
      • Abscess:No
      • Tumor:No
    • Diagnosis
      • Benign prostatic hyperplasia

[SOAP]

  • 2023-03-07 Radiation Oncology
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 frcations of the rectal to sigmoid colon tumor bed area.
  • 2023-03-07 Hemato-Oncology
    • Arrange admission for C/T (FU or FOLFOX).
    • If the PET indicates as a mets, C/T regimen for CCRT and post-CCRT would be FOLFOX, and TNT is not necessary.
    • If the PET discloses the lesion of liver is not a mets, TNT (CCRT with FU -> FOLFOX x 6-8 cycles -> OP -> follow up) is indicated. The C/T regimen for CCRT would be FU.
    • note ChatGPT:
      • In the context of oncology, TNT stands for “Total Neoadjuvant Therapy.” This refers to a treatment approach where chemotherapy, radiation therapy, or both are given before surgery for the treatment of certain types of cancer. The goal of TNT is to shrink the tumor and potentially increase the chances of a successful surgical outcome.

[chemotherapy]

  • 2023-04-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-04-11

  • The patient has been admitted for the 2nd dose of FOLFOX regimen, and there were no remarkable adverse reactions observed after the 1st dose.
  • On 2023-04-10, the lab results showed grossly normal blood counts, kidney and liver function, and selected electrolytes, indicating that scheduled chemotherapy is not contraindicated.
  • he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary.
    023-03-08 CEA: 217.89 ng/mL
    2023-02-25 CEA: 193.69 ng/mL
  • The patient’s blood pressure readings are acceptable, but the serum glucose level remains high and unstable, ranging from 229mg/dL to 150mg/dL, and should be monitored closely. If the high serum glucose level persists, metformin may be considered, given the patient’s non-insufficient kidney function.
  • No issues with medication reconciliation have been identified.

2023-03-23

  • The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.

  • On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.

  • According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.

    • Blood sugar level 148 -> 105 -> 170 -> 173 -> 127 -> 243 mg/dL

701464758

230411

[exam findings]

  • 2023-04-07 Ascites tapping
    • 3000 ml light red color ascites was drained.
  • 2023-04-03 Ascites tapping
    • After echo localization, paracentesis was performed at RLQ and 3000ml straw-colored scites was drained out with 18Fr cathether.
  • 2023-03-29 ECG
    • Sinus rhythm with Premature atrial complexes
    • Poor wave progression
  • 2023-03-29 KUB
    • Abdominal ascites
    • increased air in nondistended loops of small bowel over abdomen and pelvic ,could be mechanical ileus.
    • marginal spurs of multiple vertebral bodies
  • 2023-03-29 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Elevation of both hemidiaphragms may be due to abdominal ascites and supine position
    • Linear band subsegmental atelectasis at lung bases
    • Multiple nodules in both lungs due to metastases.
  • 2023-03-20 Ascites tapping
    • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 3000 ml for drainage, orange color and symptom relief.
  • 2023-03-17 PET
    • Glucose hypermetabolism in a focal area about ascending colon and some adjacent lymph nodes. Primary colon malignancy with some adjacent lymph node metastases may show this picture.
    • Multiple glucose hypermetabolic lesions in bilateral lungs and in the liver, compatible with multiple lung and liver metastases.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
  • 2023-03-15 All-RAS + BRAF
    • ALL-RAS: Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-12 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-03-10 Patho - colon biopsy
    • Colorectum, ascending, biopsy — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
  • 2023-03-09 Colonoscopy
    • A-colon cancer with partial obstruction
  • 2023-03-09 Asictes tapping
    • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 2000 ml for drainage and symptom relief.
  • 2023-03-07 CXR
    • Solitary pulmonary nodule at RLL.
  • 2023-03-07 CT - abdomen
    • Findings
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Multiple liver and lung tumors. Massive ascites.
      • S/P cholecystectomy.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-12-19 SONO - abdomen
    • Large liver tumor in right lobe, HCC? Suggest dynamic CT or MRI study.
    • Liver cysts.

[consultation]

  • 2023-03-14 Hemato-Oncology
    • A
      • This 67 year old man is a case of ascending colon adenocarcinoma with liver and lung metastasis. We are consulted for further evaluation.
      • Please check tumor gene status for RAS and BRAF mutations (All-RAS/BRAF test), Pending tumor mismatch repair (MMR) or microsatellite instability (MSI) status (pathology IHC stains). Arrange PET for complete staging (NHI covered).
      • For metastasis colon cancer, palliative systemic chemoterapy +/- target therapy is indicated. Re-evaluate for conversion to resectable every 2-3 mo if conversion to resectability is a reasonable goal. Furthermore, consult CRS for surgery, if there is present of obstrusion, bleeding or perforation.
      • Arrange our OPD after discharge. Thanks for your consultation.
  • 2023-03-14 Colorectal Surgery
    • A
      • O
        • 2023037: CT: Wall thickening of A-colon with adjacent fat stranding and regional LAP r/o malignancy. Multiple liver and lung tumors r/o metastases. Massive ascites.
        • 20230309: Colonoscopy: One mass was noted in the ascending colon with nearly lumen obstruction biopsy — Adenocarcinoma.
        • Abdomen: distended, no tenderness or muscle guarding
      • A: Adenocarcinoma of A-colon with multiple metastases of liver and lungs, stage IVb
      • P:
        • Due to diffuse liver and lungs metastases, palliative chemotherapy with target therapy is the main treatment option
        • Surgical intervention with bypass surgery or ileostomy may be considered if obstruction symptoms developing
        • Please inform us if any problems

[medication]

  • 2023-03-21 ~ 2023-04-18 ongoing - Xeloda (capecitabine 500mg) KXELO01 2# BID

[note]

Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information

  • Dosing: Adult - Colorectal cancer, unresectable or metastatic:
    • Single-agent therapy:
      • Oral: 1,250 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle; continue until disease progression or unacceptable toxicity.
        • Note: Capecitabine toxicities, particularly hand-foot syndrome, may be higher in North American populations; therapy initiation at doses of 1,000 mg/m2 twice daily (on days 1 to 14 every 21 days) may be considered.
    • XELOX/CAPOX regimen:
      • Oral: 1,000 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle (in combination with oxaliplatin); continue until disease progression or unacceptable toxicity. Some studies administered for a duration of 8 or 16 cycles. A retrospective evaluation of a modified schedule (eg, days 1 to 7 and days 15 to 21 of a 28-day cycle) found improved tolerability and no difference in efficacy outcomes.
    • CAPOX/panitumumab:
      • Oral: 1,000 mg/m2 twice daily on days 1 to 14 every 3 weeks (in combination with oxaliplatin and panitumumab) for at least 6 cycles or until disease progression or unacceptable toxicity.

[assessment]

  • The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.

  • The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.

  • It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.

    • 2023-04-08 Stool OB 4+
    • 2023-04-01 Stool OB 3+
    • 2023-03-09 Stool OB 3+
    • 2023-04-10 HGB 9.1 g/dL
    • 2023-04-07 HGB 6.8 g/dL
    • 2023-03-29 HGB 8.3 g/dL
    • 2023-03-20 HGB 8.4 g/dL
    • 2023-03-17 HGB 8.8 g/dL
    • 2023-03-13 HGB 8.8 g/dL
    • 2023-03-09 HGB 8.4 g/dL
    • 2023-03-07 HGB 7.1 g/dL
    • 2023-03-07 HGB 5.7 g/dL
    • 2022-12-16 HGB 8.9 g/dL
  • There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.

701465149

230411

[diagnosis] - 2023-04-02 admission note

  • Mesothelioma of pleura
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension

[past history] - 2023-04-02 admission note

  • Medical PH: 1) HTN 2) BPH
  • Inguinal hernia on 2023/01/13
  • TEP and Port-A catheter insertion on 2023/01/30
  • Hypertension for 20-30 years
    • Carvedilol HEXAC 6.25mg 1# po BID
    • Noravsc 1# po QD
    • Doxaben XL 4mg 1# po QNAC    

[allergy]

  • NKDA         

[family history]

  • His parents was DM.
  • No cancer, CAD, CVA history in his family

[exam findings]

  • 2023-04-10, -04-06 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Pleura thickening in right lateral aspect is noted.
    • Partial atelectasis of RLL and RML is suspected.
    • Please correlate with CT.
    • Borderline cardiomegaly
  • 2023-04-03 SONO - chest
    • Right
      • Right side pleural effusion? -> dry tapping
      • suspect mesothelioma or post R/T related
      • suggest CXR follow up
    • Left
      • Left side negative
  • 2023-04-02 CXR
    • Right pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-04-02 ECG
    • Atrial flutter with variable A-V block
  • 2023-02-24 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Pleura thickening in right lateral aspect is noted.
    • Partial atelectasis of RLL and RML is suspected.
    • Please correlate with CT.
  • 2023-02-23 ECG
    • Nonspecific T wave abnormality
  • 2023-02-07 Bone Scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the anterior aspect of right 1st and 2nd ribs and increased activity in the maxilla, middle and lower T-spines, lower L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Two hot spots in the anterior aspect of right 1st and 2nd ribs. Bone metastases can not be ruled out. Please also correlate with other imaging modalities for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2023-02-02 CXR
    • Rt pleural effusion with loculation still visible s/p chest tube placement,
    • partial atelectasis of RLL and RML
  • 2023-02-01 PET scan
    • Glucose-hypermetabolism in the right pleura, compatible with malignant mesothelioma of pleural status.
    • Glucose-hypermetabolism in the right upper ribs, malignancy with rib involvement should be considered, suggesting bone scan for investigation.
    • Increased FDG uptake in the right inguinal region, compatible with right inguinal hernia.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Malignant mesothelioma of pleural status with suspected right upper ribs involvement by this F-18 FDG PET scan.
  • 2023-01-31 CT - abdomen
    • History and indication: mesothelioma of pleural
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
      • Minimal pneumoperitoneum.
      • A lipoma (2.8cm) in left thigh.
      • Right inguinal hernia.
      • Some poor enhancing nodules (up to 1.0cm) in liver.
      • Bil. renal cysts (up to 1.0cm).
    • IMP:
      • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
      • Minimal pneumoperitoneum.
  • 2023-01-31 ENT Hearing Test
    • PTA
      • Reliability FAIR
      • Average RE 34 dB HL; LE 31 dB HL.
      • RE normal to severe SNHL.
      • LE normal to severe SNHL
  • 2023-01-18 Patho - pleural/pericardial biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pleura, right, VATS decortication - Malignant mesothelioma, high-grade
      • Tumor subtype — Biphasic type
      • Pathology stage:pT1Nx(if cM0); AJCC stage IA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: VATS decortication
      • Specimen site: right pleura
      • Specimen size: multiple pieces, up to 2.5x 2x 1.5 cm
      • Tumor size: fragmented, at least 2 cm in greatest dimension
      • Tumor description: ill-defined, brownish and solid
      • All for sections are taken and labeled as: F2023-38FSA1-2&A:frozen control of tumor, A1-2:tumor
    • MICROSCOPIC EXAMINATION
      • Histology Type: Malignant mesothelioma
      • Histology Grade:
        • Nuclear grade 3 [Nuclear atypia score: 3 (severe);Mitotic count score: 3 (hight, > 5 mitoses/ 10 HPF); Sum: total score 6].
        • Necrosis: present
        • Overall tumor grade: High-grade
      • Resection Margins: Cannot be assessed
      • Lymphovascular Invasion: Absent
      • Perineural Invasion: Absent
      • Tumor Necrosis: Present / Absent
      • Lymph Node : Not included
      • IHC stain — Ki-67 index: 90%, CK20(-), calretinin(focal+), CK(+), chromomgranin (-), WT-(Afocal+), D2-40(focal+), P40(-), TTF-1(-), Napsin A(-), CK7(+), vimentin (+), SOX-10(-), CK5/6(-), HBME-1(focal+), SYNAPTOPHYSIN(-), GATA-3(+),S100(-).
  • 2023-01-17 Frozen Section
    • FROZEN SECTION INITIAL DIAGNOSIS:
      • Tissue, right pleural, frozen section — Malignant tumor
  • 2023-01-16 SONO - chest
    • Echo diagnosis:
      • right side moderate amount of septated pleural effusion, pig-tail drainage via right 7th ICS posterior mid-axillary
      • line was performed and bloody fluid was drained out. The bloody fluid was sent for study.
  • 2023-01-12 CT - chest
    • The CT scan of the chest was performed without IV contrast medium enhancement and revealed that:
      • Patchy consolidation over RLL. Suggest check enhanced CT scan for furthter evaluation.
      • Moderate amount of right pleural effusion with some high-density materials. Suggest correlate with enhanced study.
      • Bilateral perirenal fatty strandings.
  • 2023-01-12 ECG
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2023-01-12 CXR
    • Right pleural effusion.
    • Borderline cardiomegaly.
    • Thoracic spondylosis.
  • 2022-12-22 Bladder Sonography
    • PVR 4.81 mL

[consultation]

  • 2023-01-28 Hemato-Oncology
    • Q
      • This is a 75 y/o male with underlying disease of HTN.
      • He underwent VATS decortication due to right pleural effusion on 2023-01-17, and the pathological report revealed malignant mesothelioma.
      • We would like to consult your expertise on evaluation and treatment arrangement of the patient, thank you!
    • A
      • This 75 year old man is a case of right malignant mesothelioma (initial presentation: cough and right pleura effusion). He has underline of HTN, BPH and rigth inguinal hernia.
      • For malignant mesothelioma, we are consulted.
        • We will discuss with pahtologist regarding the subtype, e.g., epitheloid, sarcomatoid or biphasic
        • May consider CCRT with weekly CDDP followed by systemic therapy is indicated (cisplatin + pemetrexed +/- bevacizumab) or immunotherapy with dual or single
        • Please check abdominal + pelvic CT extending to chest (+/- contrast), 24hr urine CCR, auditory test
        • Please check HbsAg, Anti Hbc, Anti-HBs, Anti HCV.
        • Arrange Port A insertion
        • We will discuss with patient and family
        • We wound like to follow up this case. May take over or arrange our OPD appointment after discharge.
  • 2023-01-27 Radiation Oncology
    • A
      • A:
        • Malignant mesothelioma, high-grade, of the right pleura, s/p VATS decortication.
      • P:
        • Postoperative radiotherapy is indicated for this patient with the following indicators: Malignant mesothelioma, high-grade, of the right pleura.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter-in-law. They understand and agree to receive radiotherapy. Please consider PET for current tumor status and staging work-up. The treatment planning of radiotherapy will be started after completion of PET.

[SOAP}

  • 2023-03-30 Radiation Oncology
    • P: Go on the radiotherapy. Plan to complete radiotherapy on 2023-04-03. RTC: 2023-04-18.
  • 2023-03-16 Hemato-Oncology
    • Already strong request increasing the salt intake again and again
  • 2023-02-16 Thoracic Surgery
    • CT: R’t massive pleural effusion, cause? liver cysts., report?

[surgical operation]

  • 2023-01-30
    • Surgery: TEP
      • ChatGPT: TEP stands for Totally Extraperitoneal Repair, which is a minimally invasive surgical technique used to repair inguinal hernias. In this procedure, a small incision is made in the abdominal wall and a laparoscope is inserted, which allows the surgeon to view the hernia and repair it from the outside of the peritoneal cavity. The hernia is repaired with a mesh, which is placed over the defect to prevent the hernia from recurring. TEP is considered less invasive than traditional open hernia repair surgery and has a lower risk of complications.
    • Finding
      • Right indirect hernia type III
      • cord lipoma (+)
      • sac descend to scrotum
      • contralateral defect: none
      • post wall repair yes
      • mesh size 14x15 cm
      • absorbable tacks
      • peritoneal defect (+) cloosed with 3-0 Vicryl sutures
  • 2023-01-17
    • Surgery: VATS decortication
      • ChatGPT: VATS decortication refers to a surgical procedure performed to remove the fibrous layer of tissue (pleural peel) that covers the lung. The procedure is performed using a minimally invasive technique called Video-Assisted Thoracic Surgery (VATS), which involves making small incisions in the chest wall and using a video camera and specialized surgical instruments to access and remove the pleural peel. VATS decortication is commonly used to treat conditions such as empyema, a collection of pus in the pleural space, and hemothorax, a buildup of blood in the pleural cavity.
    • Finding
      • Bloody effusion was noted over right pleural cavity, about 800mL
      • Frozen section:carcinoma, unknown origin.
      • One 28 Fr. straight chest tube was inserted via right 8th ICS, another curved one was inserted via right 7th ICS.

[radiotherapy]

  • 2023-02-22 ~ 2023-04-03 - at 3060cGy/17 fractions of the right pleura to right upper ribs, and 4680cGy/26 fractions of the right pleura tumor bed.

[chemotherapy]

  • 2023-04-10 - pemetrexed 500mg/m2 800mg NS 100mL 10min + cisplatin 60mg/m2 100mg NS 500mL 2hr (Alimta + cisplatin, Q3W. cisplatin to normal 75mg/m2 next time)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-16 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-09 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-02 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-24 - cisplatin 40mg/m2 70mg NS 500mL 24hr + magnesium sulfate 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-04-11

  • The patient’s HGB levels have shown a decreasing trend since the start of CCRT in late Feb 2023, which could be a result of the cisplatin and radiotherapy.
    • 2023-04-10 HGB 7.4 g/dL
    • 2023-04-06 HGB 8.9 g/dL
    • 2023-04-02 HGB 8.2 g/dL
    • 2023-03-30 HGB 8.2 g/dL
    • 2023-03-23 HGB 8.9 g/dL
    • 2023-03-16 HGB 10.1 g/dL
    • 2023-03-09 HGB 10.8 g/dL
    • 2023-02-24 HGB 11.0 g/dL
    • 2023-02-07 HGB 9.8 g/dL
    • 2023-01-30 HGB 11.0 g/dL
    • 2023-01-23 HGB 11.1 g/dL
    • 2023-01-20 HGB 11.1 g/dL
    • 2023-01-19 HGB 11.0 g/dL
    • 2023-01-17 HGB 13.3 g/dL
    • 2023-01-12 HGB 13.1 g/dL
  • The combination of pemetrexed and cisplatin, incorporating prophylactic folic acid and vitamin B12, increased OS compared with single-agent cisplatin in patients with malignant pleural mesothelioma whose disease was either unresectable or who were not otherwise candidates for potentially curative surgery. ref: Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21(14):2636-2644. doi:10.1200/JCO.2003.11.136
    • 2023-04-10 MCV 100.9 fL
    • 2023-04-06 MCV 98.1 fL
    • 2023-04-02 MCV 94.8 fL

2022-04-03

The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+) Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms. After checking the PharmaCloud database, no medication reconciliation issue is found.

700450583

230410

==========

2023-04-10

[ciclosporin TDM]

On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.

2023-04-03

The patient’s kidney function results have returned to normal within the last 7 days.

2023-04-03 Creatinine 0.95 mg/dL
2023-03-31 Creatinine 2.45 mg/dL
2023-03-30 Creatinine 3.10 mg/dL
2023-03-28 Creatinine 3.74 mg/dL

2023-04-03 eGFR 98.94
2023-03-31 eGFR 33.16
2023-03-30 eGFR 25.27
2023-03-28 eGFR 20.35

2023-03-20

[cyclosporine IV to PO conversion]

  • There are different recommendations for converting CsA administration from intravenous to oral in HSCT patients, ranging from a 1:1 to a 1:3 conversion rate. For patients receiving voriconazole, it is suggested to use a 1:1 conversion rate. However, for patients receiving fluconazole without azole co-medication, a 1:1.3 substitution is recommended to prevent CsA concentrations from becoming subtherapeutic. ref: Converting cyclosporine A from intravenous to oral administration in hematopoietic stem cell transplant recipients and the role of azole antifungals. Eur J Clin Pharmacol. 2018;74(6):767-773. doi:10.1007/s00228-018-2434-4
  • Based on the intended IV dose of 190mg BID, the daily oral dose would range from 418 to 494mg. To start with, a feasible option would be to use Sandimmun Neoral, which is available as 4 100mg capsules, and 2 25mg capsules can be added to achieve the desired dose. The total dose can be divided into two administrations. However, it is important to monitor the patient’s cyclosporine blood levels at repeated intervals and make subsequent dose adjustments to avoid toxicity from high levels and possible rejection from low absorption of cyclosporine.

2023-03-10

[ciclosporin TDM]

  • Based on the system records, the blood was drawn for ciclosporin at 2023-03-09 08:35, while the medication was administered at 08:24 on the same day. If the intended purpose was to measure the trough concentration, the ideal time for blood draw should be within half an hour before medication administration. Please verify the accuracy of the system records or redraw an blood sample.

2023-03-07

[therapeutic drug monitoring for cyclosporine]

  • The dosage of cyclosporine has remained at 170mg Q12H since 2023-03-02. A blood sample was taken correctly on 2023-03-06 morning, just half an hour before the next scheduled administration. The trough level result was 266.6ng/mL, which falls within the target range of 100 to 400ng/mL without an issue.
  • Based on the trough level result falling within the target range, no dosage adjustment is necessary.

[assessment]

  • Today (2023-03-07) marks the 12th day since the Matched Unrelated Donor Allogeneic Peripheral Blood Stem Cell Transplantation. From the lab data, there is a noticeable upward trend in WBC count in the past two days, which is a positive sign.
    • 2023-03-06 D 11 WBC 0.70 x10^3/uL
    • 2023-03-05 D 10 WBC 0.28 x10^3/uL
    • 2023-03-03 D 8 WBC 0.01 x10^3/uL
    • 2023-03-02 D 7 WBC 0.01 x10^3/uL
    • 2023-03-01 D 6 WBC 0.01 x10^3/uL
    • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    • 2023-02-26 D 3 WBC 0.04 x10^3/uL
    • 2023-02-24 D 1 WBC 0.07 x10^3/uL
    • 2023-02-23 D 0 WBC 0.01 x10^3/uL
    • 2023-02-22 D -1 WBC 0.01 x10^3/uL
    • 2023-02-20 D -3 WBC 0.09 x10^3/uL
    • 2023-02-19 D -4 WBC 0.09 x10^3/uL
    • 2023-02-17 D -6 WBC 0.23 x10^3/uL
    • 2023-02-15 D -8 WBC 0.86 x10^3/uL
    • 2023-02-13 D-10 WBC 1.36 x10^3/uL
    • 2023-02-12 D-11 WBC 1.70 x10^3/uL
    • 2023-02-10 D-13 WBC 4.40 x10^3/uL
    • 2023-02-08 D-15 WBC 9.26 x10^3/uL

2023-03-03

[therapeutic drug monitoring for cyclosporine]

  • The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.

  • The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.

  • Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.

2023-03-01

[cyclosporine TDM]

  • The cyclosporine TDM result was 79.3 ng/mL, with the blood sample drawn on February 27, 2023 at 09:09:34 and the medication given at 08:46 on the same day.
  • Since the blood sample was drawn shortly after the medication was given, the measured concentration is unlikely to be a trough concentration.
  • If a trough concentration is desired, a new blood sample should be drawn and tested.

2023-02-24

[therapeutic drug monitoring]

Sandimmun injection (ciclosporin)

  • The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.

  • Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.

  • It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.

2023-02-09

  • 2023-02-08 Cre 0.72mg/dL, eGFR 136, BUN 19mg/dL, Bil T 0.7mg/dL, Bil D 0.1mg/dL, ALT 455 U/L, AST 123 U/L. The kidneys do not appear to be degraded.
    • Patient body height 180cm, body weight 97kg => BSA 2.2m2
  • Selected chemotherapy drugs in the FuCyMito conditioning regimen
    • fludarabine 30mg/m2 => 66mg, compatible with D5W, NS, L-Ringer’s
      • 250mL NS, 1h is recommended.
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, dosage adjustment for hepatic impairment is not likely necessary (Krens 2019).
    • cytarabine 2000mg/m2 => 4400mg, compatible with D5W, D5NS, Sterile water for injection
      • 500mL NS, 6hr is recommended. (according to Trad Chinese package insert, max conc is 100mg/mL)
      • Dose may need to be adjusted in patients with liver failure since cytarabine is partially detoxified in the liver. There are no dosage adjustments provided in the manufacturer’s labeling.
    • mitoxantrone 6mg/m2 => 13.2mg, compatible with D5W, D5LR, D5NS, NS, L-Ringer, Ringer
      • 500mL NS, 3hr is recommended.
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, clearance is reduced in hepatic dysfunction.

2023-01-30

  • The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.

  • Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.

    • 2023-01-30 S-GOT/AST 60 U/L
    • 2023-01-28 S-GOT/AST 67 U/L
    • 2023-01-27 S-GOT/AST 78 U/L
    • 2023-01-30 S-GPT/ALT 129 U/L
    • 2023-01-28 S-GPT/ALT 154 U/L
    • 2023-01-27 S-GPT/ALT 193 U/L
  • In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.

    • 2023-01-30 WBC 76.58 x10^3/uL
    • 2023-01-29 WBC 73.19 x10^3/uL
    • 2023-01-28 WBC 77.15 x10^3/uL
    • 2023-01-27 WBC 94.09 x10^3/uL
    • 2023-01-30 Blast 61.9 %
    • 2023-01-29 Blast 58.7 %
    • 2023-01-28 Blast 59.6 %
    • 2023-01-27 Blast 61.0 %
  • The PLT count has been trending downward, which should be closely monitored.

    • 2023-01-30 PLT 87 x10^3/uL
    • 2023-01-29 PLT 85 x10^3/uL
    • 2023-01-28 PLT 111 x10^3/uL
    • 2023-01-27 PLT 148 x10^3/uL
  • The active prescription does not pose a problem.

2023-01-27

[drug identification]

  • We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.

  • Not used:

    • The drug to be identified has not been received until the end of the working day.
    • As of the end of working hours, the drug to be identified has not been received.

700698086

230410

[exam findings]

  • 2023-04-10 SONO - abdomen
    • Parenchymal liver disease
    • Fatty liver, mild
    • Mild CBD dilatation
    • Chronic kidney disease
    • Urinary retention
    • Minimal ascites
  • 2023-04-06 MRI - brain
    • MR of the brain and MRA of the intracranial vessels and neck carotid systems were performed on a 1.5 T superconducting magnet on supine position utilizing head coil with 6 mm slice thickness and 24 cm field of view without intravenous injection of Gadolinium.
    • Findings:
      • One small cavernous malformation (5.3mm) over right posterior corona radiata.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • Mild paranasal sinusitis.
  • 2023-03-28 CXR
    • Solitary pulmonary nodule at right lower lung zone.
    • Normal appearance of trachea and bil. main bronchus.
    • Cardiomegaly.
  • 2023-03-28 ECG
    • Sinus tachycardia
    • Voltage criteria for left ventricular hypertrophy
  • 2023-03-07 CT - brain (at TMUH)
    • Computed tomography of the BRAIN was performed without i.v. contrast administration.
    • Findings:
      • No evidence of acute intracranial hemorrhage (ICH) or space occupying lesion is noted in this study.
      • Widening of the cortical sulci of bilateral cerebral hemispheres, mild dilatation the ventricles, the findings are indicating diffuse brain atrophy, due to aged brain change.
      • Normal mastoid air cells, no evidence of mastoiditis.
      • The paranasal sinuses are clear.
      • Clinical correlation and follow up is needed.
    • IMPRESSION:
      • No evidence of acute ICH or space occupying lesion is noted.
      • Diffuse brain atrophy, due to aged brain change.
  • 2022-11-07 CT - chest (at TMUH)
    • Findings: Chest CT without IV contrast study that show: Lung window-setting is also obtained.
      • Still focal consolidative lesion and internal amorphous calcifications in LLL, relatively prominent, as compared with prior CT on 2022-08-19, consistent with post-treatment change.
      • New small nodules in RLL, favored metastatic nodules.
      • Mild left pleural effusion.
      • Mild fibrotic foci in bilateral lungs.
      • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.
      • Degenerative spondylosis with marginal spur over thoracolumbar spine.
      • Otherwise, there is no evidence of masses in the anterior, middle and posterior compartment.
      • The hilar region on each side is unremarkable, and the main bronchi appear normal.
      • There is no lymphadenopathy and there are no perihilar masses.
      • The heart has a normal configuration; the cardiac chambers are normal size.
      • No evidence of abnormalities of liver, GB, pancreas, spleen, bilateral kidneys and adrenal glands.
    • IMPRESSION:
      • Post-treatment change of LLL, with focal consolidations and internal amorphous calcifications, relatively prominent, as compared with prior CT on 2022-08-19. Recommend follow-up.
      • But new presence of RLL metastatic nodules.
      • Mild left pleural effusion.
      • Mild fibrotic foci in bilateral lungs.
      • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.

[consultation]

  • 2023-04-06 Neurology
    • Q
      • Impression
        • Acute delirium, suspected psychotic symptoms due to other medical condition, especially brain metastesis and renal failure
      • Suggestion
        • Treat malignancy and renal failure first. Non-contrast brain MRI could not clearly show malignancy. Please arrange contrast-enhanced brain CT instead, but beware of deterioration of renal failure and risk of developing end-stage renal failure.
        • Please consult neurosurgeon for brain metastasis treatment.
        • Check TSH, free T4, cortisol, ACTH, VDRL, vitamin B12, and folic acid. Treat them accordingly if abnormal findings.
        • I agreed with the psychiatrist’s suggestion of anti-psychotic medication (quetiapine). Please contact psychiatrist for further anti-psychotic drugs adjustment.
  • 2023-04-03 Nephrology
    • Q
      • For poor renal function, we need your further evaluation and management.
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was well, speech was coherent and showed no signs of distress. His limbs were not edematous.
      • He complained of poor appetite and minimal fluid intake over the past few days. Blood tests showed progressively deteriorating renal functions but he still urinates approximately 1L everyday.
        • 2023-04-03 BUN 65 mg/dL
        • 2023-04-03 Creatinine 5.29 mg/dL
      • Our advices are as follow:
        • consider ketosteril 2 PC PO TID
        • Keep daily I/O balance
        • CKD diet (Low K, low P)
        • Arrange renal sonography
        • OPD follow up prn
      • Please feel free to contact us should you require further assistance.
  • 2023-04-03 Psychosomatic Medicine
    • Q
      • The patient is restless and keeps saying he wants to find Chen Shui-bian, claiming that Chen Shui-bian is his friend. He is making phone calls everywhere and asking for money from anyone he meets, and he keeps saying that he is going to die. He throws all his belongings on the bed and ties the IV stand to the bed curtain.
    • A
      • This 80-year-old married man previously worked in the construction industry. According to his daughter, he was able to arrange his life and had good memory and daily function, such as supervising construction work in Luodong and taking walks in the park, until one week ago when he developed agitated and disruptive behaviors, such as attacking family members and lying down on the road. He also experienced auditory hallucinations, reality distortion, and hallucinatory behaviors, such as believing that Chen Shui-bian would come to talk to him for 15 minutes every day and telling him to do things. Poor sleep and disturbing behaviors persisted after admission, such as frequently borrowing money from the nursing station and seeking out Chen Shui-bian. The other hospital had diagnosed him with brain metastases. Brain MRI showed white matter intensities.
      • During the mental status examination, he displayed incoherent and irrelevant speech, disorientation (unable to tell the date or how many days he had been hospitalized, and thought he was at VGHTPE), talkativeness, auditory hallucinations, reality distortion, and hallucinatory behaviors.
      • IMP:
        • Acute delirium
        • Suspected Psychotic disturbance due to other medical condition (brain metastesis)
      • Suggestion:
        • Treat physical disease if possible.
        • DC mirtazapine, DC anxiedin. DC PRN haldol. Add utapine 25mg 1# HS, 1# HSPRN. Bini-U 5mg IM PRNQ6H if severe disturbing. Monitor ECG and QTC.
        • Tapper codeine and morphine use if possible.

[SOAP]

  • 2023-03-28 Medical Emergency
    • Hx of
      • Rectal cancer adenocarcinoma T3N0M0, stage IIA post anterior resection on 2015/1/23 and received radiotherapy about 45 Gy/25 fractions from 2015/02/23 to 2015/03/27 and lung metasteses, T3N0M1, stage IV in 2020, ECOG:2
      • Suspect obstructive pneumonitis
      • Left side pleural effusion
      • Hypertension
      • Chronic kidney disease, stage 4
    • Preliminary impression
      • C20 Malignant neoplasm of rectum
      • Agitation, Hx rectal Ca s/p op, R/T, lung metas (not treated), K 7 (hemolysis), F/U K 5, hsT 45 to 40, Hb 9, Cr 4.7, Hx HCVD, CKD

[multiteam]

  • 2023-03-31 Social Service
    • Referral Date: 2023-03-29
    • Reason for Referral: Patient and family members have emotional distress during hospitalization
    • Status: Not opening a case
    • Reason for Not Opening a Case: On 2023-03-30, separate interviews were conducted with the patient and the patient’s daughter:
      • Family Situation:
        • The patient is an 80-year-old married man with three daughters and one son. He is suffering from rectal cancer and has received treatment at TMUH in the past. He used to live alone in Yilan, but has been living with his son’s family in Taipei in recent years.
        • The patient’s wife is bedridden; the patient’s children are all married. The patient’s son and daughter-in-law currently live with the patient and the patient’s daughter in Zhonghe District. The patient’s daughter is currently unemployed and takes care of the patient full-time.
      • Assessment and Treatment:
        • The patient was admitted to the hospital due to a suicide attempt, which had been reported upon his arrival at the emergency department.
        • A social worker visited the patient’s ward today and found that the patient’s mood was stable, and he even smiled during the conversation. The patient said that he was feeling emotionally stable at the moment, but had trouble sleeping the night before. He was only able to fall asleep after being given sleeping pills. The patient also said that he did not remember what had happened before his hospitalization and was unsure who he was living with now.
        • The social worker talked with the patient’s daughter, who said that the patient’s recent abnormal behavior was likely caused by his illness, and the patient has forgotten what had happened during that time. The patient’s mood is stable when there are family members accompanying him. The patient’s daughter said that the patient has not yet received treatment from any relevant departments regarding his condition. However, she plans to take the patient to see a neurologist and other relevant departments in the future. The patient’s daughter is also currently taking care of the patient full-time and will continue to monitor his emotional changes.
        • This referral provides the above assessment and treatment information. It is confirmed that the patient’s suicide attempt had been reported upon his arrival at the emergency department. During his hospitalization, the patient’s mood has been stable, and he has cooperated with relevant medical treatments. The patient’s children are supportive and able to monitor his emotional changes in a timely manner. There are currently no emerging issues.

701240721

230410

[diagnosis] - 2023-04-07 discharge note

  • Left lip and left buccal cancer, cT4aN2cM0, stage IVA

[exam findings]

  • 2023-03-20 Nasopharyngoscopy
    • Findings
      • left nasal cavity clear, nasopharynx smooth, mucus at right nasopharynx, oropharynx and hypopharynx np
    • Diagnosis/Conclusion
      • left buccal and upper and lower lip cancer
  • 2022-09-12 ECG
    • Atrial fibrillation
  • 2022-05-05 MRI - larynx
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:4a(T_value) N:2c(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • 2022-05-05 Patho - duodenum biopsy
    • Duodenum, bulb, biopsy — capillary hemangioma
  • 2022-05-04 PET
    • Glucose hypermetabolism in the left buccal region, compatible with the primary left buccal cancer.
    • Glucose hypermetabolism in the left cervical lymph nodes and bilateral submandibular lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    • Glucose hypermetabolism in the right N-P region, the nature is to be determined (another primary NPC, metastatic lesion, inflammation/infection process or others ?), suggesting biopsy for further investigation.
    • Glucose hypermetabolism in bilateral palatine tonsils, probably inflammation/infection process.
    • Left buccal cancer, cT4aN2cM0, stage IVA (AJCC, 8th ed.); suspected another right N-P tumor, nature ? by this F-18 FDG PET scan.
  • 2022-05-03 ECG
    • Atrial fibrillation with rapid ventricular response
    • Abnormal ECG
  • 2022-04-19 Patho - gingival/oral mucosa biopsy
    • Labeled as “lower lip area”, biopsy — squamous cell carcinoma.
    • Labeled as “left buccal area”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stain: p16 (-).

[SOAP]

  • 2022-09-26 General Surgery
    • bulla aspiration
  • 2022-05-12 Ear Nose Throat
    • left lip and left buccal SCC, cT4aN2cM0
    • patient hope bony structure preservation
    • explanation about induction chemotherapy + op (wide excision + left MRND + right SND + tracheotomy + free flap reconstruction) + post-op CCRT
    • consult GS for port-A insertion

[chemotherapy]

  • 2023-04-06 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-22 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-30 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-11 - docetaxel 40mg/m2 50mg NS 200mL 1hr + cisplatin 40mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-04 - docetaxel 40mg/m2 70mg NS 200mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-20 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 4000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-14 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 4000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

[note]

TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11)

Neoadjuvant Chemotherapy regimen

  • TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
    • Q3W for 1~3 cycles
    • H&N commission suggestion
    • References: Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
  • Induction Chemotherapy modified with TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU + Leucovorin 1000mg/m2 + 100mg/m2 IVD (24 hs) D2, 9
    • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
    • H&N commission suggestion
    • References: Modified from Jerome Fayette et al. Oncotarget 2016;7(24):37297-37304

[assessment]

  • There was a gap in follow-up from early 2022-12 to mid 2023-03. The recommended dose of docetaxel and cisplatin in the TPF regimen for head and neck cancer, as listed in the in-hospital collection of chemotherapy regimens as of 2022-02-11, was 40mg/m2 for both drugs. However, the actual administered doses of the two drugs ranged from 50mg to 80mg. For fluorouracil, except for the first 2 doses at 4000mg, all other administrations since 2022-11 were at 3000mg.
  • If the patient’s dyspnea occurred on 2023-04-06 or 2023-04-07, the TPF dose administered on 2023-04-06 (the 7th dose) was docetaxel 60mg, cisplatin 60mg, and fluorouracil 3000mg all at a reduced amount, which might be less likely to cause dose-dependent adverse reactions. Is it possible that the patient experienced an infusion reaction? If this possibility cannot be ruled out, it may be worth trying a slower infusion rate or adding famotidine 20mg IVD as part of premedication in the next administration.

700183019

230406

[exam findings]

  • 2023-02-08 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
  • 2023-02-08 MRI - nasopharynx
    • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T:2(T_value) N:2cP16-, N2 P16+(N_value) M:0(M_value) STAGE:IVA P16-; II P16+(Stage_value)
  • 2023-02-07 SONO - abdomen
    • Liver cyst, S7
    • Gallbladder polyp or stone
  • 2023-01-27 Patho - nasopharyngeal/oropharyngeal biopsy
    • Tonsillar, left, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated (p16+)
    • Immunohistocyhemical stain reveals p16: positive (> 90%), CK: positive, and P40: positive
  • 2023-01-20 Nasopharyngoscopy
    • Findings
      • refer from neuro OPD
      • Suggest ENT evaluation.
    • Diagnosis/Conclusion
      • Nasopharyngoscope:
        • left deviated septum, bil. boggy turbinate
        • although NP was smooth, but MRI showed mild mucosal thickening at right lateral nasopharyngeal recess.
      • Oral:
        • left tonsillar hypertrophy - tumor lesion should rule out
        • biopsy done
  • 2023-01-12 MRA - brain
    • Indication: still complained about vertigo and unsteadiness
    • IMP:
      • Cerebral small vessel disease.
      • Mild mucosal thickening at right lateral nasopharyngeal recess. Suggest ENT evaluation.
  • 2022-11-16 Mini-Mental Status Examination
    • MMSE 23
  • 2022-11-16 Clinical Dementia Rating
    • CDR 0.5
  • 2022-11-10 Brainstem auditory evoked potentials, BAEP
    • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
    • Conclusion: This is a normal BAEP study.
  • 2022-11-10 Neurosonology
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Normal PSV in bilateral ICA and CCA. Normal ICA/CCA PS ratio bilaterally
    • Adequate total VA flow (135) may suggest no evidence of VBI
  • 2021-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83.5 - 18.3) / 83.5 = 78.08%
      • M-mode (Teichholz) = 78.1
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with trivial MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size

[chemotherapy]

  • 2023-03-22 - carboplatin AUC 2 120mg D5W 500mL with NS 1000mL (CCRT, carboplatin determ by AUC 2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-15 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-07 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.

  • Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.

    • Topical lidocaine solutions provide pain relief but require frequent administration. In one trial, topical viscous lidocaine (2 percent) was more effective than diphenhydramine and saline, a kaolin and pectin suspension, or placebo. ref: Treatment of radiation- and chemotherapy-induced stomatitis. Otolaryngol Head Neck Surg. 1990;102(4):326-330. doi:10.1177/019459989010200404
    • Topical lidocaine is frequently combined with cleansing and/or coating agents, a mixture that is often referred to as “miracle mouthwash.” There is no fixed formulation, and these mixtures are compounded differently by individual pharmacies, most of which have no set formula. ref: Survey of topical oral solutions for the treatment of chemo-induced oral mucositis. J Oncol Pharm Pract. 2005;11(4):139-143. doi:10.1191/1078155205jp166oa
  • Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.

  • The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.

  • If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.

700360398

230406

[diagnosis] - 2023-04-03 discharge note

  • Immune thrombocytopenic purpura
  • Essential (primary) hypertension

[lab data]

  • 2023-02-23 HBsAg Nonreactive

  • 2023-02-23 HBsAg (Value) 0.35 S/CO

  • 2023-02-23 Anti-HCV Nonreactive

  • 2023-02-23 Anti-HCV Value 0.07 S/CO

  • 2023-02-23 Anti-HBs 11.15 mIU/mL

  • 2023-02-23 Anti-HBc Reactive

  • 2023-02-23 Anti-HBc-Value 6.43 S/CO

  • 2023-02-23 Anti-HBc IgM Nonreactive

  • 2023-02-23 Anti-HBc IgM Value 0.10 S/CO

  • 2023-02-10 ANA Negative

  • 2023-02-10 LA1 39.3 sec

  • 2023-02-10 LA2 30.7 sec

  • 2023-02-10 LA1/LA2 ratio 1.2

  • 2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL

  • 2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL

  • 2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL

  • 2023-02-08 Anti-ENA Sm 1.2 EliA U/ml

  • 2023-02-08 Anti-ENA RNP 1.1 EliA U/ml

[SOAP]

  • 2023-03-10 Hemato-Oncology
    • Plan:
      • continue steroid therapy
      • arrange admission for mabthera therapy
  • 2023-02-15 Hemato-Oncology
    • Assessment:
      • ITP, suggest steroid therapy 1 mg/kg
    • Plan:
      • continue steroid x 1 week
      • suggest bone marrow study if persisted thrombocytopenia
  • 2023-02-08 Hemato-Oncology
    • S/O
      • He was referred on account of thrombocytopenia, referred from Cardinal Tien Hospital. Dr. Ou
        • 2021-10-24 PLT 135K/cumm
        • 2023-01-11 PLT <10K
        • 2023-01-16 PLT <10K
        • 2023-01-25 PLT <10K
        • 2023-02-08 PLT <10K
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: NKA.
      • Travel history: No traveling history within one month.
      • Occupation: None
    • Assessment
      • ITP, suggest steroid therapy 1 mg/kg
    • Plan
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR

[immunotherapy]

  • 2023-04-03 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
  • 2023-03-17 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
  • 2023-02-23 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL

[assessment]

  • The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.

  • The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.

    • 2023-04-03 PLT 7 x10^3/uL
    • 2023-03-24 PLT 6 x10^3/uL
    • 2023-03-17 PLT 27 x10^3/uL
    • 2023-03-10 PLT 4 x10^3/uL
    • 2023-03-01 PLT 113 x10^3/uL
    • 2023-02-27 PLT 13 x10^3/uL
    • 2023-02-24 PLT 21 x10^3/uL
    • 2023-02-23 PLT 1 x10^3/uL
    • 2023-02-22 PLT 1 x10^3/uL
    • 2023-02-15 PLT 1 x10^3/uL
    • 2023-02-08 PLT 2 x10^3/uL
  • Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.

  • In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.

700028729

230403

{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}

[diagnosis] - 2023-04-02 admission note

  • Malignant neoplasm of upper lobe, right bronchus or lung
  • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Chest pain, unspecified
  • Acute kidney failure, unspecified

[past history]

  • Denied history of Hypertension, DM, asthma
  • Denied any operation, accident and other medical Hx.                            

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes. 

[exam findings]

  • 2023-04-02, -03-09, -02-10, -02-06 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • S/P port-A implantation.
    • Patchy opacity projecting in the right upper lung shows stationary.
    • Peri-bronchial wall thickening of bilateral lower lung zone is noted, which may be due to old inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-24 MRI - branchial plexus
    • Indication: right arm pain from shoulder to arm, twitching like. better on lying down and hot packing. motion exacerbated.
    • Phx: lung ca.
    • MRI of brachial plexus without/with Gadolinium-based contrast enhancement shows:
      • multiple heterogeneously enhancing tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
      • multiple high signal lesions in visible spine and ribs, compatible with bone metastases.
      • massive left pleural effusion.
    • Impression:
      • Multiple tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
      • Multiple ribs and spine metastases.
  • 2023-01-19 SONO - nephrology
    • Left small kidney with chronic parenchymal changes.
    • Hyperechoic pyramids, both kidney, suspected nephrocalcinosis secondary to hypercalcemia, suspected gout or anagelsic nephropathy.
    • Bilateral plerual effusions.
  • 2023-01-17 Abdomen - standing (diaphragm)
    • Right side Pneumothorax with air-fluid level at right CP angle.
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • There are several small stones in bilateral kidney?
    • Please correlate with sonography.
    • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
  • 2023-01-16 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 950ml yellowish, clear
      • Pleural tapping 16 #-needle Left side 1080ml yellowish, clear
    • Echo diagnosis:
      • Bilateral massive pleural effusion, post left diagnostic and bilateral therapeutic thoracentesis.
  • 2023-01-14, -01-05 CXR
    • Patchy opacity projecting in the right upper lung
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Emphysematous change of both lung field
  • 2022-12-29 CT - chest

EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB

Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)

Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP

Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation

Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.

  • 2022-12-27 SONO - chest
    • Bilateral thorax: large amount pleural effusion s/p drainage of left side, 850 cc, yellowish pleural effusion.
  • 2022-12-06 KUB
    • There are several small stones in bilateral kidney? Please correlate with sonography.
    • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
  • 2022-09-28 CT - abdomen

History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT:RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB

MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.

This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.

Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.

IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.

  • 2022-09-28 KUB
    • increased air in nondistended loops of small bowel over LUQ and LLQ, could be paralytic ileus.
  • 2022-09-28 CXR
    • areas of hyperlucency and decreased lung vascular markings dirty marking due to emphysematous change of both lungs upper lung predominance
    • ill-define consolidation in peripheral of RUL due to tumor
  • 2022-08-09 ALK Immunostaining Result
    • The immunostaining of the section slide labeled S2022-11085, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-07-20 CT - brain
    • no evidence of brain tumors.
  • 2022-07-26 ROS1 fluorescent-in-situ hybridization (FISH) report
    • Result
      • Number of invasive tumor cells counted: 50
      • Number of observers: 1
      • Number of cells (%) classified as negative: 48 (96%)
      • Number of cells (%) classified as positive: 2 ( 4%)
    • Interpretation
      • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-07-15 PD-L1 (SP142)
    • Pathologic Report for VENTANA PD-L1 (SP142) Assay for Non-Small Cell Lung Cancer
      • Tumor type: Adenocarcinoma, metastatic
      • Tumor location: Liver
      • Testing assay: SP142 Assay (Ventana)
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=100 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor Cell Staining Assessment:
        • PD-L1 Expression: Absence of any discernible PD-L1 membrane staining in tumor cells (TC < 50%)
      • Tumor Infiltrating Immune Cell Staining Assessment:
        • PD-L1 Expression: < 3% Immune cells (IC < 10%)
    • Note:
      • Percent of PD-L1 expression in tumor cells (TC): The percentage of viable tumor cells with membrane positivity at any intensity
      • Percent of PD-L1 expression in immune cells (IC): The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
  • 2022-07-15 EGFR mutation
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
      • EGFR Status: no mutation detected
      • EGFR Mutation Status: no mutation detected
    • Description
      • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
  • 2022-07-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 25 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees, in whole body survey.
    • IMPRESSION:
      • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees.
  • 2022-07-12 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, consistent with lung primary
    • The sections show a picture of adenocarcinoma, composed of liver tissue with nests and cords of polygonal neoplastic cells in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
    • IHC shows: CK7(+), CK20(-), TTF1(+), Arginase-1(-), and Hepatocyte(-). The finding is consistent with metastatic adenocarcinoma, lung primary.
  • 2022-07-09 CTA - chest
    • PH: emphysema
    • With and Without contrast Chest CT and CTA showed
      • emphysematous change in the bilateral lung fields; a heterogeneous enhancing lesion, about 52mm, in the upper lobe of the right chest. suspected chest wall or pleural tumor or lung tumor. Irregular margins was noted.
      • multiple heterogeneous ill-defined tumors in the bilateral lobes of the liver, esp. left side
      • small bilateral renal stones.
    • IMP:
      • suspected right pleural or lung tumor
      • mulitple hepatic tumors
  • 2022-07-05 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1c(M_value) STAGE:____(Stage_value)
  • 2022-07-02 CXR
    • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
    • Rt apicolateral pleural effusion or thickening

[SOAP]

  • 2022-09-22 Hemato-Oncology
    • EGFR, ROS1, ALK all wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB
    • No fit for cisplatin doublet due to imparied renal function
      • ChatGPT: “Cisplatin doublet” is a type of chemotherapy regimen used to treat various types of cancer, such as lung cancer, bladder cancer, and ovarian cancer. It consists of a combination of two chemotherapy drugs, with cisplatin being one of them, and the other drug depending on the specific cancer being treated. The doublet regimen is used to increase the effectiveness of chemotherapy by combining two drugs with different mechanisms of action, which can enhance tumor cell kill and reduce the likelihood of drug resistance.
  • 2022-08-23 Hemato-Oncology
    • Fail alimta but starting with weekly taxane
  • 2022-07-29 Hemato-Oncology
    • BH 169, BW 52
    • EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stage IVB

[chemotherapy] (not completed)

  • 2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)

  • 2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)

  • 2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)

  • 2022-11-03 - ditto

  • 2022-10-25 - ditto

  • 2022-10-18 - ditto

  • 2022-10-06 - ditto

  • 2022-09-22 - ditto

  • 2022-09-15 - ditto

  • 2022-09-01 - ditto

  • 2022-08-25 - ditto

  • 2022-08-10 - ditto

  • 2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[medication]

  • G-CSF (filgrastim 150ug) CGCSF01
    • 2022-12-26 - 2022-12-26 IPD
    • 2022-12-13 - 2022-12-13 OPD
    • 2022-11-29 - 2022-11-29 OPD
    • 2022-08-23 - 2022-08-23 OPD
    • 2022-08-07 - 2022-08-07 IPD
  • Granocyte (lenograstim 250ug) CGRAN01
    • 2023-01-12, 13, 14 - 2023-01-12 OPD

[assessment]

  • The patient is currently undergoing supportive and palliative treatment to alleviate his symptoms.
  • Cisplatin was not administered due to his insufficient renal function.
  • He experienced several episodes of leukopenia during chemotherapy, for which G-CSF was used to mitigate the side effects.
  • The last dose of docetaxel was administered on 2023-01-05.

700871378

230403

[diagnosis] - 2023-04-02 admission note

  • Diffuse large B-cell lymphoma, unspecified site
  • Essential (primary) hypertension
  • Chronic viral hepatitis B without delta-agent

[past history]

  • hypertentsion under medication control for 20+ years

[allergy]

  • NKDA                             

[family history]

  • Younger sister has lymphoma

[lab data]

2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index

[exam findings]

  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 11.9) / 82.6 = 85.59%
      • M-mode (Teichholz) = 80.1
      • 2D(M-simpson) = 75.3
    • Conclusion:
      • Thickened AV with mild AR
      • Normal MV with no MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, mildly dilated LA
  • 2023-02-17 Myocardial perfusion SPECT with persantin
    • The Tl-201 stress myocardial perfusion SPECT performed after intravenous injection 33.6 mg of dipyridamole revealed mildly decreased perfusion of radioactivity to the apex and inferolateral wall. The Tl-201 redistribution myocardial perfusion SPECT revealed reperfusion of radioactivity to the defects and mildly decreased perfusion of radioactivity to the posterior wall.
    • IMPRESSION:
      • Probably mild myocardial ischemia at the apex and inferolateral wall.
      • Mild reverse redistribution of radioactivity to the posterior wall, either normal variant or myocardial ischemia may show this picture.
  • 2023-02-16 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-02-16 CT - chest
    • Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Minimal fibrotic change at left lingula lobe is found. Probably due to previous RT
        • The left breast tumor cannot be visualized in the study.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Bilateral renal cysts are found
        • The spleen, liver, pancreas and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp:
      • Left breast cancer s/p RT and C/T without evidence of recurrent/residual tumor in the lung fields.
      • Suggest closely follow up.
  • 2022-11-02 CT - chest
    • Impression:
      • resolution of Lt breast tumor compared with CT on 2022-07-28.
      • extensive V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
  • 2022-09-24 KUB
    • S/P left femoral operation.
    • Atherosclerosis of the aorta.
  • 2022-08-02 Patho - bone marrow biopsy
    • Bone marror, biopsy— Negative for malignancy
    • Immunohistochemical stain revesls CD 20 (sparse +, < 5%), CD138 (sparse +, < 2%), CD71(+), MPO(+).
  • 2022-08-01 Whole body PET scan
    • Glucose hypermetabolism lesions in the left breast (Deauville score 5), compatible with lymphoma in the left breast.
    • Glucose hypermetabolism lesions in the left N-P region (Deauville score 5) and in bilateral axillary regions (Deauville score 3-4), the nature is to be determined (lymphoma or chronic inflammation/infection process ?), suggesting further investigation.
    • Glucose hypermetabolism lesions in bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature.
    • Lymphoma in the left breast, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-07-28 CT - lung
    • Left breast cancer with left hilar lymphadenopathy
  • 2022-07-14 Patho - breast biopsy
    • Breast, left, core biopsy — Diffuse large B-cell lymphoma, in favor of non-GCB type
    • Section shows cores of breast tissue with invasion of large, pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. The results are in favor of non-GCB type of diffuse large B-cell lymphoma.
  • 2022-07-12 SONO - breast
    • Diagnosis:
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
        • clacification
        • lipomas
    • Plan:
      • Core-needle biopsy
    • Suggestion:
      • Regular OPD follow-upsonography guided core biopsy of L’t breast tumor (1,1)
      • BI-RADS 4A - low suspicion for malignancy Biopsy Should Be Considered
  • 2022-07-04 Mammography
    • A 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast.
    • BI-RADS category 0, Need additional imaging evaluation.
    • Suggest ultrasound correlation for left breast tumor.

[consultation]

  • 2023-04-03 Vascular Surgery
    • Q
      • A case of Triple hit ,non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
        • will receive PBSC harvest this time, we need your expertise for double lumen insertion on 2023/04/14, thanks
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, this patient is a 69 year old female seen in consultation for opinion regarding treatment options for double lumen insertion on 2023-04-14.
      • The pt’s hx/Dx was noted for
        • Diffuse large B-cell lymphoma, unspecified site
        • Essential (primary) hypertension
        • Chronic viral hepatitis B without delta-agent
      • Lab/CXR reviewed.
      • SUGGESTION & PLAN:
        • double lumen insertion will be arranged on R’t side on 2022/04/14 under LA, 8 AM.
  • 2023-02-09 Dermatology
    • Q
      • This 69 y/o woman has hypertentsion under medication control for 20+ years. She suffered from a 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast mammography on 2022/07/05.
      • Owing to the symptom exacerbation, the patient called at our OPD for help. Breast sono showed highly suspicious of malignancy, with sonographic negative axillary LNs1 on 2022/07/16.
      • Biopsy on 2022/07/21 showed Diffuse large B-cell lymphoma, in favor of non-GCB type. CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. CT of chest was performed on 7/29 revealed Left breast cancer with left hilar lymphadenopathy.Port-A insertion on 2022/07/29. PET on 2022/08/01 showed glucose hypermetabolism lesions in the left breast, left N-P region, bilateral axillary regions, bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature. Bone marrow biopsy on 2022/08/02 showed negative of maglignancy. Under the diagnosis of Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1.
      • She received C1 R-DAEPOCH (Vincristine not available) on 2022/08/03 ~ -08/08. C2 R-DAEPOCH was administered on 2022/08/29 ~ -09/03, C3 R-DAEPOCH on 2022/10/14 ~ 10/19.
      • Urgency and frequency was noted in August, 2022. Klebsiella pneumoniae urinary tract infection was noted.
      • Followed up CT on 2022/11/02 revealed resolution of Lt breast tumor compared with CT on 2022/07/28. extensive V-CAD,suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
      • C4 R-DAEPOCH on 2022/11/14 ~ 2022/11/19.
      • She received the radiotherapy at 3240cGy/18 fractions of the left breast from 2022/12/6 ~ 12/31
      • However, Radiation dermatitis was noted after the radiotherapy. We need your expertise for further management,thanks
    • A
      • The patient had sufferred from itchy erythematous papules and plaques over left breat region.
      • Under the impression of post-radiation dermatitis
      • The following sugeetion:
        • keep oral allegra 1# bid use.
        • Rinderon-V cream 2 tube topical bid use over erytheamtous lesions first, if stable shift to Mycomb cream 1 tube bid use -> (Anti-inflammatory and redness-reducing)
          • body cream mix-up with sinphradem cream 1 tube (1:1) topical QN use.

[radiotherapy]

  • 2022-12-06 ~ 2022-12-31 - 3240cGy/18 fractions of the left breast

[chemoimmunotherapy] (not completed)

  • 2023-04-03 - rituximab 375mg/m2 598mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 1hr D2-5 + etoposide 40mg/m2 63mg NS 250mL D2-5 + cisplatin 25mg/m2 40mg NS 500mL 18hr D2-5 + cytarabine 2000mg/m2 3000mg NS 500mL 2hr D6 (R-ESHAP)
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + NS 250mL D1-6 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-6
  • 2023-02-10 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + [etoposide 50mg/m2 77mg + vincristine 0.4mg/m2 0.6mg + doxorubicin 10mg/m2 15mg + NS 250mL] 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg NS 500mL 1hr D6 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-DAEPOCH)
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + NS 250mL D1-5 + acetaminophen 500mg PO D1 + granisetron 2mg D2-6
  • 2023-01-12 - ditto R-DAEPOCH
  • 2022-11-14 - ditto R-DAEPOCH
  • 2022-10-14 - ditto R-DAEPOCH
  • 2022-08-29 - ditto R-DAEPOCH
  • 2022-08-03 - rituximab 375mg/m2 580mg 8hr D1 + etoposide 50mg/m2 77mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg 1hr D6 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 (R-DAEPOCH without vincristine)

[note]

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)

  • R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
    • Administration – R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
    • Adverse effects – Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
    • Outcomes – A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

==========

2023-04-03

  • This time, the patient was admitted for PBSC collection.

2022-08-18

  • It is the first time the patient receive her first chemotherapy in this hospitalization.
  • 2022-08-17 CRP 7.2 mg/dL, 2022-08-18 01:14 body temperature 38.4 degree, Sintrix (ceftriaxone) and Mycostatin (nystatin) have been prescribed.

701134216

230403

[diagnosis] - 2023-04-01 admisstion note

  • Sepsis, unspecified organism
  • Fever, unspecified
  • Malignant neoplasm of rectosigmoid junction
  • Unspecified jaundice

[present illness] - 2023-04-01 admisstion note

  • The 57 y/o man has R-S colon with liver and bone mets s/p OP with colostomy on 2021 and closure it at Cardinal Tien Hospital in early 2023, chemotherapy also at that hospital, postive of anti-HBc.

[exam findings]

  • 2023-04-01 CT - abdomen
    • history: Rectal ca with liver mets and bone mets s/p OP with colostomy
    • With and without contrast enhancement CT of abdomen shows:
      • Recosigmoid colon CA, s/p operation.
      • Multiple lung metastasis.
      • Multiple liver metastasis.
      • Peritoneal nodules, r/o peritoneal carcinomatosis.
      • Enlarged lymph nodes in para-aortic region.
      • Mild compression fractures of L2,3,4.
    • Impression
      • Recosigmoid colon CA, s/p operation
      • Liver, lung, and lymph node metastasis
      • Peritoneal carcinomatosis
  • 2023-03-31 CXR
    • Multiple nodules at bil. lungs.
  • 2018-07-31 Fingers Rt
    • comminuted fracture of distal phalanx, 4th finger post pin fixation
  • 2018-06-19 Fingers Rt
    • fracture of distal phalanx, 4th finger post pin fixation, stable
  • 2018-06-15 Fingers Rt
    • Crush injury with distal phalange destruction is found.
    • Regional soft tissue swelling is identified.

[SOAP]

  • 2023-03-23 Hemato-Oncology
    • Admission for bilirubinemia then C/T
  • 2023-03-16 Hemato-Oncology
    • Last dose of Avastin plus FOLFOXIRI on 2023-03-09.
    • Apply cetuximab

[assessment]

  • The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.

  • The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.

    • 2023-03-31 Alkaline phosphatase 996 U/L
    • 2023-03-31 S-GPT/ALT 50 U/L
    • 2023-03-31 Bilirubin direct 4.26 mg/dL
    • 2023-03-31 Bilirubin total 7.42 mg/dL
    • 2023-03-23 Bilirubin total 6.09 mg/dL
    • 2023-03-14 Bilirubin total 8.87 mg/dL
  • Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.

  • The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.

  • According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.

700324624

230331

[diagnosis] - 2023-03-30 admission note

  • Malignant neoplasm of unspecified site of left female breast
  • Pleural effusion, not elsewhere classified
  • Acute pulmonary edema
  • Dyspnea, unspecified

[exam findings]

  • 2023-03-29 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Incomplete right bundle branch block
    • Possible Right ventricular hypertrophy
    • Possible Anterolateral infarct, age undetermined
    • Abnormal ECG
  • 2023-03-29 CTA - chest
    • Indication: Bilateral lower leg edema with shortness of breathing
    • With and Without contrast Chest CT and CTA showed
      • dilated main PA.
      • unremarkable change in the main bronchial trees and the visible trachea
      • consolidation in the lower lobes of the bilateral lung; two nodular lesions, about 17mm, in the upper lobe of the right lung; another small nodular lesion, about 14mm, in the upper lobe of the left lung.
      • moderate bilateral pleural effusion
      • unremarkable change in the chest wall
    • IMP:
      • nodular lesions in the upper lobes of the bilateral lung
      • moderate bilateral pleural effusion.
      • consolidation in the lower lobes of the bilateral lung.
      • no evidence of DAA or PE.
  • 2023-03-29 CXR
    • Unremarkable change in the visible trachea
    • Normal cardiac and vascular shadows
    • Lung markings: consolidation in the right lung field and left lower lung field
    • blurred bilateral hemidiaphrams
    • blunting bilateral costophrenic angles
    • Unremarkable change in bilateral clavicles

[assessment]

  • The patient’s renal function is showing signs of recovery.
    • 2023-03-31 Creatinine 0.91 mg/dL
    • 2023-03-29 Creatinine 1.33 mg/dL
    • 2023-03-31 eGFR 63.55
    • 2023-03-29 eGFR 41.01
  • On 2023-03-31, Ocillina (oxacillin sodium), Rolikan (sodium bicarbonate), and 0.9% saline were prescribed, which may relieve hyponatremia.
    • 2023-03-31 Na (Sodium) 131 mmol/L
    • 2023-03-29 Na (Sodium) 123 mmol/L
  • Hypokalemia was observed on the morning of 2023-03-31, which may be due to the administration of furosemide, which was started on 2023-03-30 after normal serum potassium was detected on 2023-03-29. There were 3 bowel movements without diarrhea recorded on 2023-03-30.
    • 2023-03-31 K(Potassium) 3.3 mmol/L
    • 2023-03-29 K(Potassium) 4.0 mmol/L
  • Please consider prescribing a potassium supplement if necessary and continue to closely monitor the patient’s serum electrolytes. An alternative option is to consider using the combination of furosemide and spironolactone with adequate sodium supplementation and blood pressure monitoring to prevent hypotension.

700892422

230331

[diagnosis] - 2023-03-10 discharge note

  • Squamous cell carcinoma of left upper lip cT4aN0M0 cstage IVA in process chemotherapy
  • Infection of the upper lip
  • Encounter for antineoplastic chemotherapy
  • Hypertension
  • Verrucous carcinom of right buccal mucosa and tongue post of 2017.

[exam findings]

  • 2023-02-01 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two faint hot areas at the T7 and L2-3 spines, respectively, faint hot spots in both rib cages, and increased activity in the maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • Two faint hot areas at the T7 and L2-3 spines, respectively, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in both rib cages, maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-01-31 MRI - nasopharynx
    • Indication: Malignant neoplasm of upper lip, inner aspect
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A upper lip tumor mass, up to 4.4 cm, with bone destruction.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Multiple oral cavity cancers s/p operation.
    • IMP: Upper lip CA, T4N0M0 Stage IVA.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4A(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
  • 2023-01-31 SONO - abdomen
    • GB stone, multiple
    • Adenomyomatosis of GB
  • 2023-01-30 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Inferior infarct , age undetermined
    • ST & T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2023-01-05 Patho - gingival/oral mucosa biopsy
    • Chronic red lesion, left upper lip, incisional biopsy — Cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated
    • Microscopically, the sections show a picture of some subepithelial cysts with focal surface opening (fistula-like) lined by well-differentiated squamous cells and focal irregular epithelial hyperplasia with dyskeratosis as well as focal epithelial hyperplasia within inflamed and fibrous stroma. According to histopathologic finding and patient’s past history, it is compatible with well-diifferentiated squamous cell carcinoma.
  • 2019-06-19 MRI - nasopharynx
    • SOAP
      • S: He is a patient with double oral cancer at lip and cheek seperately and received operations.
      • O: oral ulcer with malignant potential on the inner surface of left upper lip is noted but improved after injection treatment.
      • A:
        • Dysplasia of right buccal mucosa (2018-01)
        • Verrucous carcinoma of right tongue (2017-05-10)
        • SCC of left buccal mucosa and retromolar area post OP (2015-04)
        • Verrucous carcinoma of right tongue border (2017-05)
        • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
      • P
        • check BUN and creatinine before MRI examination
        • arrange MRI examination with contrast to evaluate undermining tumor status
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1-WI (thickness=5 mm, gap=1mm) and sagittal T1WI (thickness= 4 mm, gap=1 mm) and show:
      • Post-operation change at left upper lip, left buccal region, and right tongue border, without abnormal soft tissue intensity, nor abnormal enhancement.
      • An oval-shaped nodular lesion, about 16 mm x 10 mm, at left supraclavicular region, r/o an enlarged lymph node, mildly enlarged as compared with MRI on 20180815. Suggest further evaluation and close follow-up.
      • No remarkable finding at nasopharynx, oropharynx, hypopharynx and larynx.
      • No remarkable finding at parotid, submandibular and sublingual glands.
      • No remarkable finding at skull base and visible intracranial structures.
      • Mucosal thickening in bilateral ethmoid and maxillary sinuses, indicating chronic paranasal sinusitis.
    • IMP: C/W multiple oral cavity cancers s/p operation, without evidence of recurrence based on this study. A suspicious enlarged lymph node at left supraclavicular fossa. Suggest further evaluation (such as PET) and close follow-up.
  • 2018-08-15 MRI - nasopharynx
    • CC: He is a patient with double oral cancer at lip and cheek seperately. He has mild pain at his left upper lip for few days. He also has rough surface lesions on his both cheeks for weeks and mouth-opening limitation for years. He had received cancer surgery on 2015-04. He wears unfitted denture.
    • Indication:
      • S: He is a patient with double oral cancer at lip and cheek seperately. He had received cancer surgery on 2015-04 and 2017-05. He wears unfitted denture.
      • O: ulceration on the left upper lip is noted. that is probablly due to unfit denture. abnormal scar tissue with fungus patches on the bil. buccal mucosa is noted.
      • A:
        • Dysplasia of right buccal mucosa (2018-01)
        • Verrucous carcinoma of right tongue (2017-05-10)
        • Dysplasia of right buccal mucosa,and the right lower lip (2017-05-10)
        • SCC of left buccal mucosa and retromolar area post OP (2015-04)
        • Verrucous carcinoma of right tongue border (2017-05)
        • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
      • P:
        • Chech BUN and creatinine before MRI examination
        • Arrange MRI with contrast to evaluate the undermining tumor status
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
      • No abnormal mass lesion in the nasopharynx, oropharynx, hypopharynx or larynx.
      • No neck LAP.
      • Normal appearance of parotid, submandibular and thyroid glands.
      • Mild mucosal thickening of bilateral maxillary sinuses.
      • Mucosal thickening of rightinferior nasal turbinate.
    • Impression:
      • No obvious buccal or oropharynx mass or nodule.
  • 2017-11-20 MRI - nasopharynx
    • No obvious buccal or oropharynx mass or nodule.
  • 2017-05-10 Surgical pathology Level IV
    • Clinical diagnosis: Chronic periodontits
    • Patho DIAGNOSIS:
      • Labeled as “tumor of right buccal mucosa”, wide excision — Verrucous hyperplasia with submucosa fibrosis.
      • Labeled as “tumor of right tongue”, wide excision — Verrucous carcinoma, margin free of malignancy.
      • Tongue, right, wide excision — Verrucous carcinoma
      • Lymph node—- N/A.
      • Pathology stage: pT1Nx (cM0); pStage: I.
    • MACROSCOPIC EXAMINATION CHECKLIST
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: right tongue
        • Other part(s) included: right buccal mucosa
        • Lymph node dissection: no
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: right tongue: 1.2 x 0.9 x 0.35 cm.
        • Additional dimensions: right buccal mucosa: 1 x 0.8 x 0.4 cm.
      • Tumor Site: right tongue, Laterality : right
      • Tumor Focality : single focus
      • Tumor Size: Greatest dimension: 0.25 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 1.5 mm
      • Mucosal Surface : Intact
      • Gross Tumor Extension : submucosa
    • MICROSCOPIC DESCRIPTION:
      • Section of the “tumor of right buccal mucosa” shows verrucous hyperplsia.
      • Section of the “tumor of right tongue” shows one piece of hyperkeratotic squamous mucosa with verrucous carcinoma 2.5 mm in width and 1.5 mm in depth. The tumor is 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
    • MICROSCOPIC EXAMINATION CHECKLIST:
      • Histologic Type: Verrucous carcinom
      • Histologic Grade: G1: Well differentiated
      • Microscopic Tumor Extension: submucosa
      • Margins: Margins free, Distance from closest margin: 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: N/A.

[consultation]

  • 2023-02-01 Thoracic Surgery
    • Q
      • For port-A insertion
      • This is a 57 y/o male patient denied of HTN, CAD and DM major disease.
      • His oral tumor of left upper lip biposy reported cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated (sample number: S2023-00290) on 2023-01-05.
      • His nasopharnyx MRI showed upper lip T4AN0M0 stage IVA.
      • His treatment plans were induction chemotherapy follow by surgery and CCRT.
      • He was admitted to ward for tumor work up and prepare induction chemotherapy.
      • We need your help for port-A insertion, Thanks!           
    • A
      • I will arrange insertion of port-A this week. Thanks for your consultation!

[SDM] - 2023-02-02

  • This afternoon, we had a meeting with Mr. Ding and his son to discuss the current status of his illness and future treatment options.
  • Dr. Xia:
    • Mr. Ding, your oral cancer examination has been completed. Currently, the diagnosis is stage III left upper lip oral cancer, which can be diagnosed by direct visual inspection or palpation. However, the magnetic resonance imaging (MRI) report shows that the cancer has invaded the adjacent maxilla bone, so it is stage IV left upper lip oral cancer. The purpose of this family meeting is to discuss your treatment options and the potential side effects of each treatment method. In general, your treatment for left upper lip oral cancer will include surgical resection of the tumor and removal of lymph nodes. Depending on the pathology report, radiotherapy may also be necessary after the surgery. Since your cancer is located in the left upper lip, we will take into consideration the future appearance, clarity of speech, and the side effects of lip dysfunction. Therefore, there are two treatment options that we can discuss, and we will arrange appropriate treatment according to your decision.
      • Treatment option 1: Directly remove the left upper lip oral cancer tumor by surgery. The advantage of this method is that it removes the cancer faster, and it makes the existence of left upper lip oral cancer invisible to the eyes and mind. However, the disadvantage of this method is that the tumor area removed is larger, which will affect your appearance in the future. Losing the upper lip will also affect the clarity of your speech, and you will lose the function of closing your lips, causing food and water to spill out while eating and drinking.
      • Treatment option 2: Use chemotherapy first to kill the left upper lip oral cancer cells. The advantage of this method is that if the chemotherapy is effective, it can shrink the tumor and reduce the surgical area in the future, thus reducing the impact on your appearance. It also reduces the impact on speech clarity and the chance of food and water spilling out while eating and drinking. The disadvantage of this method is that you will first face the side effects of chemotherapy, such as nausea, vomiting, diarrhea, decreased white blood cells causing infections, and even life-threatening conditions, anemia, hair loss, and weakness, etc. Have you and your family understood this?
  • Mr. Ding:
    • Yes, I have heard and understood. How effective is chemotherapy?
  • Dr. Xia:
    • Each person’s oral cancer cells have different characteristics, so the response to chemotherapy will also be different. Basically, about 80% of oral cancer patients respond well to chemotherapy, which can reduce the size of the oral cancer. However, we can only know if it works after injection, and cannot predict it in advance.
  • Mr. Ding:
    • I understand. How long will the chemotherapy last? How do I know if it is effective?
  • Dr. Xia:
    • This chemotherapy will last for about two months. We will treat you in cycles every three weeks, with three cycles in total, so the chemotherapy will last for a total of nine weeks. Simply put, chemotherapy is administered in the first and second weeks, and you will rest at home in the third week. Chemotherapy will resume in the fourth week, and so on. The entire chemotherapy process will last nine weeks. Two weeks after the end of chemotherapy (around the 11th week), you will undergo surgical treatment. I have a chemotherapy manual for you and your family to refer to. As for whether it is effective, it can only be known after injection, and the patient can feel and see whether the tumor has shrunk. So currently, I cannot know whether the chemotherapy will be effective for you.
  • Mr. Ding: What if chemotherapy is not effective?
  • Dr. Xia: I will schedule surgery to remove

[surgical operation]

  • 2017-05-10
    • Diagnosis: Severe dysplasia of right buccal mucosa with maliganant tendency
    • PCS code: 92014C Complicated extraction
    • Finding
      • Abnormal macule (patch) of erythroplakia 1cm x1.5cm at right buccal mucosa WAS NOTED.
      • Abnormal mass on the right tongue 0.5cm x0.5cm WAS NOTED.
      • Severe trismus is noted
      • Enlongation and caries of 17 16 25 34 32 33 34 48 47

[chemotherapy]

  • 2023-03-31 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg NS 500mL 22hr + leucovorin 80mg/m2 150mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-22 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-06 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-27 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-13 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-03 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg NS 500mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy

[assessment]

  • The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.

    • 2023-03-29 WBC 3.84 x10^3/uL
    • 2023-03-20 WBC 3.46 x10^3/uL
    • 2023-03-10 WBC 4.19 x10^3/uL
    • 2023-03-06 WBC 4.86 x10^3/uL
    • 2023-02-27 WBC 4.16 x10^3/uL
    • 2023-02-17 WBC 3.63 x10^3/uL
    • 2023-02-13 WBC 6.36 x10^3/uL
    • 2023-02-10 WBC 2.80 x10^3/uL
    • 2023-01-31 WBC 5.32 x10^3/uL
  • The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.

  • According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.

  • By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.

    • 2023-03-29 HGB 9.9 g/dL
    • 2023-03-20 HGB 10.7 g/dL
    • 2023-03-10 HGB 11.4 g/dL
    • 2023-03-06 HGB 10.9 g/dL
    • 2023-02-27 HGB 12.6 g/dL
    • 2023-02-17 HGB 12.2 g/dL
    • 2023-02-13 HGB 13.8 g/dL
    • 2023-02-10 HGB 15.5 g/dL
    • 2023-01-31 HGB 14.0 g/dL

701469037

230331

[diagnosis] - 2023-03-09 admission note

  • Hypopharyngeal squamous cell carcinoma with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC s/p chemotherapy with with PF (CDDP 75mg/m2 D1 + 5-Fu 1000mg/m2 D1-4) from 2023/02/07~
  • Chronic viral hepatitis B without delta-agent
  • Constipation, unspecified
  • Hypercalcemia
  • Hypomagnesemia
  • Hyponatremia

[lab data]

  • 2023-01-30 HBsAg Reactive
  • 2023-01-30 HBsAg (Value) 686.57 S/CO
  • 2023-01-30 Anti-HCV Nonreactive
  • 2023-01-30 Anti-HCV Value 0.13 S/CO
  • 2023-01-30 HIV Ab-EIA Nonreactive
  • 2023-01-30 Anti-HIV Value 0.06 S/CO
  • 2023-01-30 Anti-HBc Reactive
  • 2023-01-30 Anti-HBc-Value 8.95 S/CO
  • 2023-01-30 Anti-HBs 6.17 mIU/mL

[exam findings]

  • 2023-03-30 CT - abdomen
    • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
      • Known a case of right hypopharyngeal cancer. Still presence of this tumor at right pyriform sinus. One enlarged node (4.4cm) over right level IV of neck.
      • Multiple liver metastases.
      • Minimal ascites.
      • Focal atrophy of left kidney with stone (2mm).
      • Small amount of bilateral pleural effusion.
      • Multiple osteoblastic lesions of T-L spine, may be metastatic lesions.
      • S/P N-G tube insertion.
  • 2023-03-09 CXR
    • Mild Increased infiltration over both lower lungs. May be active infection.
  • 2023-02-06 Patho - colorectal polyp
    • Colorectum, descending colon (60 cm from anal verge), Polypectomy — Tubular adenoma with low grade dysplasia
    • Colorectum, rectum Size (10 cm from anal verge), Biopsy removal — Tubular adenoma with low grade dysplasia
  • 2023-02-02 CT - abdomen
    • History and indication: left tongue cancer, cT4aN2CM0, echo with multiple liver lesionfor liver tumors, suspected HCC, suspected metastasis
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Multiple liver metastases.
      • Minimal ascites.
      • Focal atrophy of left kidney with stone (2mm).
      • S/P NG tube indwelling.
    • IMP:
      • Multiple liver metastases.
  • 2023-02-01 Whole body PET scan
    • Glucose-hypermetabolism in the right hypopharynx, compatible with the primary hypopharyngeal cancer.
    • Glucose-hypermetabolism in the middle to basal aspect of tongue and bilateral cervical lymph nodes, highly suspected advanced cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in both lobes of the liver and multiple bones, highly suspected cancer with distant metastases.
    • Hypopharyngeal cancer with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-01 Patho - esophageal biopsy
    • Labeled as “esophagus, 35 cm below incisor”, biopsy — squamous mucosa with high grade dysplasia.
    • Section shows squamous mucosa with high grade dysplasia.
    • The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical, and if available, image findings. Further work up might be considered.
  • 2023-01-31 Patho - larynx biopsy
    • Labeled as “right hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
    • IHC stains: p16(+, 95%), CK5/6 (+), p40 (+), Ki-67 (90%).
  • 2023-01-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Suspected esophageal mucosal lesion, L/3, s/p biopsy
    • Esophageal inlet patch, U/3
    • Superficial gastritis
    • C/W hypopharyngeal cancer
  • 2023-01-31 SONO - abdomen
    • multiple hepatic tumors, both lobe
  • 2023-01-30 ECG
    • Sinus tachycardia with short PR
    • Right atrial enlargement
    • Nonspecific ST abnormality
    • Abnormal QRS-T angle, consider primary T wave abnormality
    • Abnormal ECG
  • 2023-01-30 Laryngoscopy
    • right hypopharyngeal tumor
  • 2023-01-26 Nasopharyngoscopy
    • Findings:
      • smooth NPx; right hypopharyngeal mass involved right AE fold, pyriform sinus and laryngx with airway narrowing
    • Diagnosis/Conclusion
      • right hypopharyngeal tumor, favor malignancy
      • left tongue cancer
  • 2023-01-24 CT - neck
    • Neck CT with and without IV contrast enhancement shows:
      • Soft tissue mass occupying hypopharynx more on right side measuring 4.9cm with partially obliteration of the supraglottic airway is found. Some lymphadenopathy at bilateral neck mostly at right neck is found.
      • Abnormal necrotic lesion at tongue about 4.65cm in largest dimension is found.
      • Mild wall thickeing at upper third esophagus is found.
      • Intact bony alignment over cervical spine
    • Imp:
      • Probably tongue cancer with bilateral neck lymphadenopathy and hypopharyngeal exntesion.
    • Imaging Report Form for Oral Cavity Carcinoma
      • T4aN2c
  • 2023-01-24 Nasopharyngoscopy
    • Findings:
      • ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
      • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
      • smooth nasopharynx, oropharynx, no pharyngeal wall bulging
      • tumor mass over right hypopharynx
    • Diagnosis/Conclusion
      • mass lesion over posterior tongue, right retromolar trigone region, right hypopharynx
  • 2023-01-19 Pathology (at TuCheng Hospital)
    • SNOMED: 53000-A-M80703
    • DX: Tongue, “posterior”, incisional biopsy — squamous cell carcinoma
    • GROSS D: The specimen submitted consists of a piece of tissue measuring 0.7 x 0.5 x 0.3 cm. Submitted in toto. LYC
    • MICRO D: Sections show squamous mucosa with invasive nests of tumor cells displaying squamous differentiation.

[consultation]

  • 2023-02-26 Hemato-Oncology
    • Q
      • Consultation for take over and chemotherapy.
      • This 48 year-old man is diagnosed of (1) left tongue squamous cell carcinoma T4aN3bM1, stage IVc and (2) right hypopharyngeal squamous cell carcinoma T3-4aN3bM1, stage IVc.
      • After discussing with him and his family, he decided to undergo chemotherapy. Colonoscopy is arranged on 2023/02/06 10:30 due to hyperdensity lesion over upper rectum in abdominal CT.
      • We need your expertise to take over this patient and start chemotherapy as your plan. Thank you very much!
    • A
      • According to tumor board discussion, please arrange colonoscopy due to hyperdensity lesion over upper rectum in abdominal CT r/o colonrectal cancer.
      • In addition, please arrange 24 urine CCR and auditory test. Please book 11A and transfer to our service. Thanks for your consultation.
  • 2023-01-24 Ear Nose Throat
    • A
      • S
        • Sorethroat for a month
        • Right neck progressive swelling for a week
        • A(+)/B(-)/C(+, 1 PPD for 20 years)
        • voice change (+, for a month), trismus (-), oral bleedeing (-), dyspnea (- **), otalgia (-), fever (-), dysphagia (+, mild)
        • Posterior tongue SCC diagnosed at 土城 hospital on 2023/01/16
      • O
        • Oral cavity and oropharynx: ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
          • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
        • Neck : 6 cm non-movable painful firm mass over right neck level III-V region
        • Scope: smooth nasopharynx, oropharynx, no pharyngeal wall bulging
          • tumor mass over right hypopharynx
        • CT: heterogenous mass lesion over posterior tongue, right hypopharynx
          • mild deviated but still visible air way, 3 cm heterogenous mass lesion over right neck
      • A
        • Posterior tongue squamous cell carcinoma
        • Mass lesion over right hypopharynx, r/o metastasis, r/o second primary tumor
        • Right neck heterogenous mass, r/o metastasis
      • P
        • prohylatic antibittics with augmentin, keep oral hygeine with parmason, and adequate pain control (acetaminophen, ultracet, or self-paid comfflam) if no contraindication
        • ENT OPD f/u on 2023/01/26 AM
        • Well education. if disease progression (bleeding, short of breath…), back to ER soon

[SOAP]

  • 2023-03-23 Hemato-Oncology
    • Tx Plan: Neoadjuvant TPF followed by CCRT
    • Cancer Multidisciplinary Team Meeting Conclusion
      • Meeting Date: 2023-02-03
      • Treatment Plan:
        • Systemic therapy + Local radiation therapy.
        • Team consensus: Tongue + Hypopharynx: cT4aN3bM1, IVC.

[chemotherapy]

  • 2023-03-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-07 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-31

2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.

There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)

2023-03-10

  • The patient is undergoing the PF regimen treatment for the second time during this hospital stay and did not experience discomfort symptoms within two weeks after the previous chemotherapy.
  • Lab results (2023-03-09) indicate the presence of hypercalcemia (2.78mmol/L), hypomagnesemia (1.6mg/dL), and hyponatremia (130mmol/L).
    • Cisplatin treatment is known to cause hyponatremia, hypomagnesemia, and hypocalcemia, as noted in “Electrolyte Disorders Induced by Antineoplastic Drugs” (Front Oncol. 2020;10:779. Published 2020 May 19. doi:10.3389/fonc.2020.00779).
    • Hypercalcemia, which is typically caused by increased osteoclastic bone resorption and affects up to 10 to 30% of cancer patients (ref: Electrolyte disorders with platinum-based chemotherapy: mechanisms, manifestations and management. Cancer Chemother Pharmacol. 2017;80(5):895-907. doi:10.1007/s00280-017-3392-8), has been confirmed to be present due to bone metastases. If this causal relationship is confirmed, the primary treatment approach would be to administer intravenous bisphosphonates. However, it’s worth noting that this treatment may potentially lower magnesium levels as well.

700029976

230330

[present illness] - 2023-03-29 admission note

This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.

[past history]

  • Raynaud phenomenon
  • Waldenstrom’s macroglobulinemia
  • Diabetes Type II
  • right lung adenocarcioma RLL status post VATS wedge resection
  • prostatic cancer status post TURP

[allergy]

  • NKDA         

[family history]

  • Dad and mum have diabetes mellulitus.
  • Denied any cancer history.

[SOAP]

  • 2023-03-15 Hemato-Oncology
    • BT with PRBC 2 U today
  • 2023-02-09 Urology
    • Malignant neoplasm of prostate
    • PSA every six months
  • 2023-02-01 Hemato-Oncology
    • BT with PRBC 2 U today
  • 2023-01-11 Hemato-Oncology
    • Waldenstrom macroglobulinemia. (IgM myeloma less likely)
    • hold endoxan and continue steroid therapy
    • continue surgar control.
    • suggest keep warm and OPD follow up.
    • suggest mabthera therapy if continue elevation of IgM

[medication]

  • 2022-04-06 ~ undergoing - Endoxan (cyclophosphamide)

[assessment]

  • The patient has been under follow-up in our Hemato-Oncology OPD due to extremely high IgM levels and was diagnosed with Waldenstrom macroglobulinemia. Cyclophosphamide treatment was initiated in April 2022.
  • The patient’s IgM levels decreased from approximately 7000 mg/dL in Q2/Q3 2021 to approximately 3000 mg/dL in Q2 2022 and have been around 2500 mg/dL since then. However, LDH levels have remained consistently high, with a record high of 1004 U/L in Q1 2023. The patient’s serum glucose levels have fluctuated between 100-200 mg/dL during the same period.
  • The current prescription is appropriate and further evaluation is ongoing.

700199716

230330

[diagnosis] - 2023-03-06 admission note

  • Malignant neoplasm of endometrium
  • Endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1
  • Polycystic ovarian syndrome
  • Iron deficiency anemia, unspecified

[past history]

  • Heart:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-) Other

  • DVT 2 years ago

  • medication: Rivaroxaban regularly and had taken Leuplin

  • Surgical: denied

  • Menstrual history: G0P0, Last menstrual period: 2022-09-25

  • sex –

  • Menarche at the age of 12 years old

  • Menstrual cycle:irregular with duration of 7 days

  • Amount: moderate with blood clots

  • Pap smear: denied                

[allergy]

  • NKDA                       

[family history]

  • There is no family history of cancer,hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-07 CT - abdomen
    • Clinical history: 49 y/o female patient with endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
      • Presence of gallbladder stones.
      • Suspected right renal cyst, 0.58cm.
    • Impression:
      • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
      • GB stones.
      • Suspected right renal cyst.
    • 2022-11-16 Peripheral Vascular Test: Vein , lower limbs
      • Chronic DVT, mild intramural thrombus involved left popliteal vein with revascularization
      • Right LSV mild reflux, involved right sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
      • Rigth CFV trivial reflux
      • Left LSV mild reflux, involved left sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
      • Left CFV trivail reflux
      • Both SSV without reflux
    • 2022-10-31 CT - chest
      • no abnormality of both lungs and mediastinum.
    • 2022-10-26 Patho - ovary (tumor)
      • PATHOLOGIC DIAGNOSIS
        • Uterus, endometrium, LAVH — Endometroid carcinoma with marked squamous differentiation
        • Lymph nodes, pelvic, bilateral, BPLND — Metastatic carcinoma
        • AJCC 8 th edition, Pathology stage: pT1aN1mi; stage IIIC1; FIGO stage IIIC1
      • MACROSCOPIC EXAMINATION
        • Procedure: LAVH + BSO + BPLND
        • Specimen Size: 10.7 x 9.5 x 3.8 cm (uterus), 3 x 2 x 2 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3 x 2 x 2 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube)
        • Specimen Integrity: Intact
        • Tumor Site: Endometrium
        • Tumor Size: Diffusely thickened, up to 2.0 cm in thickness
        • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
        • Representative parts are taken for section and labeled as: A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E1-E2= left ovary and fallopian tube, F1-F2= left ovary and fallopian tube. F2022-00502FSA1-FSA2= tumor, A1=cervix, A2= cervix + tumor, A3= parametrium, A4-A6= uterine corpus.
      • MICROSCOPIC EXAMINATION
        • Histologic Type: Endometroid carcinoma with marked squamous differentiation
        • Histologic Grade: FIGO grade 1
        • Myometrium Invasin: Present
          • Depth of Invasion: 11 mm
          • Thickness of Myometrium: 25 mm
        • Adenomyosis: Present
        • Uterine Serosal Involvement: Not identified
        • Cervical Stromal Involvement: Not identified
        • Other Tissue/Organ Involvement: Not applicable
        • Peritoneal/Ascitic Fluid: Not submitted
        • Margins: Uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 1.8 cm
        • Lymphvascular Invasion: Present
        • Regional Lymph Nodes: Metastatic carcinoma
          • number of lymph node examined: 7 (left iliac), 4 (left obturator), 4 (right iliac), 8 (right obturator)
          • number with metastases >2 mm: 0
          • number with metastases >0.2 mm and <=2 mm: 2 (left iliac), 1 (left obturator)
          • number with isolated tumor cells (<=0.2mm): 3 (left iliac), 2 (left obturator)
        • Pathologic Stage
          • Primary Tumor: pT1a (tumor limited to endometrium or less than half of myometrium)
          • Regional Lymph Nodes: pNmi (regional lymph node metastasis > 0.2 mm but <= 2 mm)
          • Distant Metastasis: Not applicable
        • FIGO Stage: Stage IIIC1
        • Additional Pathologic Findings
          • Cervix: Chronic cervicitis
          • Myometrium: Adenomyosis
          • Ovaries, bilateral: No remarkable change
          • Fallopian tubes, blateral: No remarkable change
    • 2022-10-26 Frozen Section
      • Uterus, frozen section — Malignant (endometroid carcinoma)
    • 2022-10-03 MRI - pelvis
      • Findings
        • Diffuse thickening endometrium, endometrial hyperplasia?
        • There are cysts in bilateral adnexa, could be due to ovarian cysts.
        • There are cysts in the uterine cervical region, suggesting Nabothin cysts.
        • There are lymph nodes in bilateral obturator regions, suggest follow up.
        • Non-enhancing nodules in right kidney(up to 1cm), r/o right renal cysts.
      • Impression
        • Diffuse thickening endometrium, endometrial hyperplasia or tumor? Suggest clinical correlation.
        • Nabothin cysts.
        • Bilateral obturator lymph nodes, suggest follow up.
      • Imaging Report Form for Endometrial Carcinoma
        • Impression (Imaging stage) : T:T1a(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)
    • 2022-09-15 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C — atypical endometrial hyperplasia with squamous differentiation
      • Microscopically, sections show atypical endometrial hyperplasia composed of complex atypical hyperplasia of endometrial glands with increased glandular complexity and glandular crowding with squamous metaplasia and nuclear atypia.
      • Immunohstochemical stain reveals p16(+), p53(patchy+, wild -type), vimentin(+), CEA (focal +).
    • 2022-09-15 Patho - endometrium curretage/biopsy
      • Uterus, endocervix, ECC — Squamous cell metaplasia with atypia
      • Microscopically, it shows hyperplasia of squamous cells with focal nuclear atypia.
      • Immunohistochemical stain reveals p16(+), p53(patchy+, wild-type), vimentin(+).
    • 2022-05-27, 2021-11-12, 2021-04-23, 2020-08-14 Gynecologic ultrasonography
      • LT adnexae: free
      • adenomyosis
    • 2020-11-16 Peripheral Vascular Test: Vein, lower limbs
      • Acute venous thrombosis from left ostial SFV to distal SFV with minimal recanalization at ostial and proximal SFV; acute venous thrombosis at left popliteal vein with minimal recanalization. Left ATV wasn’t seen. Patent left PTV and LSV.
      • No evidence of venous thrombosis at right lower limb venous systems.
      • Mild venous reflux at right saphenofemoral junction with no varicose change of right LSV.
      • The ratios of MVO and SVC were within normal limtis.

[surgical operation]

  • 2022-10-26
    • Surgery
      • Diagnosis
        • D&C show atypical endometrial hyperplasia with squamous differentiation
        • LAVH then sent uterus for frozen section. => Frozen: Malignant (endometroid carcinoma)
      • Operation:
        • Laparoscopic gynecologic oncology staging surgery        
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • CDS: free
      • Estimated blood loss: 100 ml
      • Blood transfusion: nil
      • Complication: nil
  • 2022-09-15
    • Surgery
      • D&C, theraputic and for diagnostic (D&C: Dilatation and Curettage)
    • Finding
      • Uterus: Anteversion, 8 cm.
      • some endometrial tissue were curetted out.
      • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.    

[radiotherapy]

  • 2022-11-30 ~ undergoing - at 2160cGy/12 fractions of the pelvic area.

[chemotherapy]

  • 2023-03-06 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-12-19 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-11-29 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + NS 250mL

==========

2023-03-30

On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy. The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition. After reviewing the PharmaCloud database, no medication reconciliation issues were identified.

2023-03-07

After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL. Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia. The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.

2022-12-20

Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.

700805458

230330

[diagnosis] - 2023-03-03 admission note

  • Malignant neoplasm of nasopharynx, unspecified
  • Chronic mucoid otitis media, right ear
  • Gastro-esophageal reflux disease with esophagitis
  • Gastritis, unspecified, without bleeding
  • Postmenopausal atrophic vaginitis
  • Unspecified cirrhosis of liver

[past history]

  • Thyroid papillary cancer status post thyroidectomy in 2008
    • Eltroxin 50mg 3# po QW2,4,6
    • Eltroxin 50mg 2# po QW1,3,5,7
  • Hepatitis B virus infection under medical treatment
    • Vemlidy 1# po QDAC
  • Polyarthralgia under medical treatment  
    • Plaquenil 1# po QOD

[allergy]

  • Omnipaque (iohexol): skin rash

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-03-03 Gynecologic ultrasonography
    • bilateral adnexae: free
    • IMP: adenomyosis
  • 2023-02-23 Patho - cervix/endometrial polyp
    • Uterus, endometrium, TCR-P— Endometrial polyp with decidual reaction
  • 2023-02-17 Hysteroscopy
    • OBS/GYN history: G 2 P 2 A ____ LMP ____
    • HSC indication/Pre-exam impression: suspect EM lesion
    • Procedure: Under lithotomy position, HSC exam was performed smoothly
    • Hysteroscopy No. : HYF-XP
    • Finding:
      • Endometrial cavity:
      • Endocervix: WNL
      • Fundus: obliterated with polyp
      • Right tubal ostium: obliterated with polyp
      • Left tubal ostium: obliterated with polyp
    • Post-exam impression: endometrial polyp
      • EBL:minimal , Complication: Nil , BT: Nil
  • 2023-02-13 Whole body PET scan
    • No previous study for comparison.
    • The lesion in the right petrous bone shown on the previous MRI of nasopharynx reveals very mildly increased FDG uptake, compatible with NPC s/p R/T.
    • Glucose-hypermetabolism in the esophagus, probably chronic inflammation process.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • NPC s/p treatment, no evidence of residual, recurrent or metastatic tumor, by this F-18 FDG PET scan.
  • 2023-02-11 SONO - abdomen
    • Cirrhosis of liver
    • GB stones/polyp, multiple
    • Hepatic cysts
    • Splenomegaly
  • 2023-02-10 Nasopharyngoscopy
    • Findings
      • bulging tumor over rt NP, subside
    • Diagnosis/conclusion
      • NPC, cT4N0M0 s/p CCRT
  • 2023-02-10 Gynecologic ultrasonography
    • LT adnexae:free
    • IMP
      • Adenomyosis
      • Uterine myoma
      • EM: 11.5mm, suspect endometrial thickening
  • 2023-02-02 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/09/08.
    • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle.
    • Regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal.
    • Favor residual tumor with progression.
  • 2023-02-02 SONO - abdomen
    • Right liver cysts (3.57x4.19cm, 1.26x1.32cm).

    • Gallbladder stones (3-5mm).

    • 2023-01-06 SONO - thyroid gland.

      • no evidence of mass lesion.
    • 2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy

      • Findings: bulging tumor over rt NP, subside
      • Summary: NPC, cT4N0M0 s/p CCRT
    • 2022-11-24 Gynecologic ultrasonography

      • Uterine myoma
      • Endometrial thickening, EM: 11.4mm
    • 2022-11-16 CT - abdomen

      • Findings:
        • There are two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
        • There are multiple gallstones.
        • The liver shows mild irregular contour that may be early cirrhosis or normal variation.
        • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
      • IMP:
        • Two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
        • Multiple gallstones.
        • Early cirrhosis of the liver is suspected.
        • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
    • 2022-09-08 MRI - nasopharynx

      • Indication: NPC s/p TPF
      • Findings:
        • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle. Regression of most of the lesion involving right nasopharynx and paraspinal spce, but mild progression of the lesion involving right petrous bone around carotid canal.
        • Mottled T2-hyperintensity in right mastoid air cells, indicating mastoiditis.
      • IMP:
        • NPC s/p treatment, partial regression of most of the tumor, but with mild progression of the lesion in petrous bone, as compared with MRI on 20220426.
    • 2022-09-01, -06-02 SONO - abdomen

      • Cirrhosis of liver
      • GB stones/polyp, multiple
      • Hepatic cysts
      • Splenomegaly
    • 2022-06-14 ECG

      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-06-14 CXR

      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-06-14 PTA

      • Reliability FAIR
      • Average RE 78 dB HL; LE 29 dB HL.
      • R’t moderately severe to profound mixed type HL.
      • L’t normal to moderate HL. (BC masking dilemma)
    • 2022-04-28 Tc-99m MDP whole body bone scan

      • The Tc-99m MDP bone scan at 4 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the skull base, L3-4 spines, bilateral shoulders, knees and both feet in whole body survey.
      • IMPRESSION:
        • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
        • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        • Mildly increased activity in the L3-4 spines. Degenerative spine disease is more likely.
        • Increased activity in bilateral shoulders, knees and both feet, compatible with benign joint lesions.
    • 2022-04-28 Gynecologic ultrasonography

      • Bilateral adnexae: free
      • Uterine myoma
    • 2022-04-27 Panendoscopy

      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, body, s/p CLO test
      • Gastric erosion, antrum, LC site
    • 2022-04-27 SONO - abdomen

      • Cirrhosis of liver with splenomegaly
      • Hepatic cysts
      • GB stones/polyp
      • Suboptimal study
    • 2022-04-26 MRI - nasopharynx

      • Indication: Nasopharyngeal carcinoma for cancer work up
        • Allergy to contrast
      • Findings
        • A large lobuated right NPx tumor mass, up to 4.3 cm, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • No evident abnormal enlarged lymph node in the visible neck.
        • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • IMP: Right NPC, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
      • Impression (Imaging stage): T:T4(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
    • 2022-04-26 PTA

      • Reliability FAIR
      • Average RE 63 dB HL; LE 28 dB HL
      • RE mild to profound MHL
      • LE normal to mild SNHL
    • 2022-04-25 ECG

      • Possible Left atrial enlargement
      • Nonspecific T wave abnormality
    • 2022-04-18 PTA

      • Reliability FAIR
      • Average RE 53 dB HL; LE 34 dB HL.
      • R’t mild to severe MHL.
      • L’t mild to moderately severe SNHL.
    • 2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy

      • Nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
      • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei, prominent nucleoli and syncytial growth pattern. Keratin formation is absent.
    • 2022-04-11 Otologic endoscopy

      • rt NP tumor
      • rt MEE
    • 2022-04-11 Nasopharyngoscopy

      • rt NP tumor
    • 2022-03-12 SONO - abdomen

      • Cirrhosis of liver
      • GB stones/polyp
      • Hepatic cysts
      • Splenomegaly
    • 2020-12-16 2D transthoracic echocardiography

      • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 25) / 89 = 71.91%
        • M-mode (Teichholz) = 72
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis and aortic root calcification; trivial TR.
      • Prominent epicardial fat.
  • consultation
    • 2022-06-21 Ophthalmology
      • Q
        • This 63-year-old woman patient is a case of Nasopharyngeal carcinoma, cT4N0M0, stage IVA. She was admitted for chemotherapy with TPF(C1D1) on 2022/06/16.
        • This time, for right eye redness with itch. Now, for evlauate right eye redness with itch therapy. Thank you.
      • A
        • S: Bilateral eye redness and itchy for 5days
        • O:
          • denied bv
          • discharge++, purulent
          • itchy++
          • BCVA od 0.4(0.5x+3.25/-4.00x90) os 0.5(0.7x+1.50/-2.00x70)
          • IOP 15/18mmHg
          • Pupil 3/3 +/+
          • MGD+
          • conj injected with purulent discharge, no pseudomembrane od>os
          • K clear ou
          • AC D/cl ou
          • Lens ns+ ou
          • Fd c/d 0.3, disc pinkish ou
        • A
          • Conjunctivitis od>os, favor EKC (epidemic keratoconjunctivitis)
        • P
          • Alminto 1gtt qid ou + tetracyclin 1qs hs
          • inform the red flags, if worsen vision, come back asap
          • opd f/u
    • 2022-04-29 Radiation Oncology
      • A
        • Diagnosis: Nasopharyngeal carcinoma, NK SqCC, undifferentiated type, cT4N0M0, with invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base and Rt ORX, ECOG =1.
        • Suggest: Radiotherapy.
          • Goal: Curative.
          • RT Plan may be designed as the following one:
            • Target & Volume: NPX tumor and neck lymphatics.
            • Technique: VMAT.
            • Dose & Fractionation: 7140cGy/34 fx, with concurrent chemotherapy.
        • Plan:
          • Either CCRT followed by adjuvant C/T or induction C/T followed by CCRT is suggested for tumor control. Possible toxicity of radiotherapy (radiation mucositis, pharyngitis, dermatitis) is told. Diet education and psychological support are given.
    • 2022-04-28 Obstetrics and Gynecology
      • Q
        • This 63 y/o woman has historiesr of hypothyroidism, hepatitis B under regular medication control. The patient was admitted for NPC work up. The patient complaint perineal itching and urgency to urinate off and on for one month. She has treated at local clinic under Genxate 1# po tid, anbicyn 1# po tid , Amoxicillin 1# po tid.
      • A
        • This 63 y/o woman, G4P2A2(cesarean section), menopaused at her age of 50.
        • The patient complaint perineal + vaginal itching in recent 3 months, urgency to urinate off and on in recent 1 month. She had been to local clinic for help where Genxate 1# po tid, anbicyn 1# po tid, Amoxicillin 1# po tid were given.
        • Lab data: grossly normal, no leukocytosis or anemia.
          • PV: severe vaginal dryness, little whitish vaginal discharge, cervical lifting pain(-)
          • TVUS: Uterus: AVFL, 77x41mm; Endometrium: 4.3mm; 2 myomas( 26x24mm, 26x25mm)
            • Bilateral adnexa: free, no pelvic mass
            • CDS: no ascites
        • IMP: Suspected postmenopausal atrophic vaginitis
        • Suggestion:
          • May keep current LMD medications
          • Add Vaginal estrogen cream (Premarin 14gm/tube) QD HS and oral metronidazole 1# QID x 3 days.
          • GYN OPD f/u if needed
    • 2022-04-26 Oral and Maxillofacial Surgery
      • Q
        • This 52 y/o woman has history of hepatitis B and hypothyroidism for years under regular medication control. She is acase of nasopharyngeal carcinoma. She was admitted for cancer work up.
        • Due to follow up radiotherapy was indicated, we request your consultation for dental evaluation.
      • A
        • This is a 63 y/o female admitted for cancer evaluation(nasopharyngeal carcinoma). This time we were consulted for dental evaluation.
        • S: Oral examination.
          • Hx: epatitis B and hypothyroidism for years under regular medication control
        • O:
          • Residual root of tooth 24, 25, 44
          • Caries of tooth 14, 15, 23 under ill-fitting prosthesis. Percussion pain and periapical radiolucency of tooth 14, 23 were noted.
          • Full mouth chronic periodontitis and poor oral hygiene was noted.
        • A:
          • Residual root of tooth 24, 25, 44
          • Caries of tooth 14, 15, 23
          • Full mouth chronic periodontitis
        • P:
          • Take panoramic film. Explain the findings and treatment plan to the patient and her family.
          • Suggest extraction of residual root of tooth 24, 25, 44 , patient and family want to consider.
          • Suggest removal of ill-fitting prosthesis and re-evaluation of tooth 14, 15, 23 , patient and family want to consider.
          • Suggest OPD follow up.

[SOAP]

  • 2023-03-29 Hemato-Oncology
    • Admission on 2023-03-28 for 4th PF and blood trasfusion due to syncope
  • 2023-02-21 Hemato-Oncology
    • EBV viral load Q3M, next in 2023-05
  • 2022-12-13 Hemato-Oncology
    • EBV viral load Q3M, next in 2023-02
  • 2022-09-20 Hemato-Oncology
    • Due to the tumor invading toward brain stem based on the MRI on 2022-09-08, should consider PF4 after CCRT.
  • 2022-08-09 Hemato-Oncology
    • Already give medication education, e.g., hold Mgo and Primperan when diarrhea, hold smecta if no more diarrhea
  • 2022-08-02 Hemato-Oncology
    • Patient sustaine Gr 1 mucositis over lip, urinary tract and GYN area, Gr 1 anorexia -> does not like to take C/T on 2022-08-02
  • 2022-07-26 Hemato-Oncology
    • If first dose of cycle -> G-CSF for 2 doses
    • If 2nd dose of cycle -> G-CSF for 3 doses
  • 2022-07-19 Hemato-Oncology
    • RTC 1 week and next C/T on 2022-07-26 for OPD 2-2 course with G-CSF suport
  • 2022-05-10 Hemato-Oncology
    • Treatment plan: induction chemotherapy with TPF x 3 (if spliting dose, that would be 6 doses) followed by CCRT with weekly CDDP

[radiotherapy]

  • 2022-09-26 ~ 2022-11-11 - 7140cGy/34 fractions (6 MV photon) to NPX tumor & neck lymphatics

[chemoimmunotherapy]

  • 2023-03-30 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2023-03-03 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2023-01-13 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2022-12-14 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2022-11-08 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-01 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-25 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-18 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-11 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-04 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-27 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-16 - docetaxel 35mg/m2 50mg NS 160mL 1hr + cisplatin 35mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-08-09 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-26 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-19 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-12 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-05 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-06-15 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 500mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3

==========

2023-03-30

  • Due to her syncope, the patient was admitted for scheduled chemotherapy and received a blood transfusion.
  • The patient is receiving PF4 regimen since Dec 2022 after CCRT due to tumor invasion towards brainstem based on MRI on 2022-09-08.
  • EBV DNA quantitative amplification results have never exceeded 120 copies/mL since Sep 2022. However, 2023-02-02 MRI showed regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal, favoring residual tumor with progression.

2023-03-06

The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.

In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.

2023-01-16

2022-12-14

  • Since October 2022, serum potassium readings have returned to normal levels:
    • 2022-12-13 3.6 mmol/L
    • 2022-11-29 3.7 mmol/L
    • 2022-11-15 4.2 mmol/L
    • 2022-11-08 3.8 mmol/L
    • 2022-10-25 3.7 mmol/L
    • 2022-10-18 3.6 mmol/L
    • 2022-10-11 3.8 mmol/L
    • 2022-10-04 3.6 mmol/L
    • 2022-09-20 3.4 mmol/L
    • 2022-08-23 3.2 mmol/L
    • 2022-08-16 3.1 mmol/L
    • 2022-08-09 3.1 mmol/L
    • 2022-08-02 3.7 mmol/L
    • 2022-07-26 3.5 mmol/L
    • 2022-07-19 4.0 mmol/L
    • 2022-07-12 3.6 mmol/L
    • 2022-07-05 3.7 mmol/L
    • 2022-06-29 4.2 mmol/L
    • 2022-06-23 3.1 mmol/L
    • 2022-06-08 4.0 mmol/L
    • 2022-05-10 4.0 mmol/L
    • 2022-04-25 3.5 mmol/L
  • It may be appropriate to reduce the dosage of the potassium supplement Radi-K (TID -> BID/QD) as well as encourage the patient to consume more potassium-rich foods. Foods with high levels of potassium include: dried figs, molasses, seaweed, dried fruits (dates, prunes), nuts, avocados, bran cereals, wheat germ, lima beans. (Renal function is normal in the patient.)

700998905

230329

[exam findings]

  • 2023-03-24 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-09 CT - abdomen
    • History and indication: Low rectal cancer involving anal canal
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of low rectum with adjacent fat stranding, anal canal/ sphincter invasion and regional LAP.
      • Gallbladder stones (3-5mm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-03-07 Patho - colorectal polyp
    • Colorectum, low rectum, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
  • 2023-03-07 Colonoscopy
    • Low rectal cancer involving anal canal s/p biopsy
  • 2023-03-02 Anoscopy
    • mixed hemorrhoid
    • low rectal mass with bleeding suspected malignancy
  • 2017-09-08 Multiple Sleep Test
    • Summary - The diagnostic nocturnal polysomngraphy demonstrated:
      • Respiratory events were both obstructive and hypopnic (obstructive: 43.6%, central: 0%, Mixed: 0% and hypopnea: 56.4%) with an AHI of 57.1. This is consistent with severe sleep apnea. Snoring was present for 20 % of the diagnostic portion of the study.
      • The baseline oxygen saturation was normal. The oxygen desaturation index was 51.8/hr. severely increased. Desaturation events were continuous and clustered. The lowest SaO2 desaturation associated with a respiratory event was 67%.
      • Sleep structure and quality was (abnormal, fragmented due to respiratory events arousals).
      • The cardiac rate and rhythm showed (normal sinus rhythm) (frequent, PAC’s, PVC’s).
    • Conclusion:
      • This is a case of severe SAS. She had abnormal sleep architecture and nocturnal oxygen desaturation. She is a snorer, too.
        • ChatGPT: SAS in this context refers to Sleep Apnea Syndrome, a condition characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep, resulting in disruptions to breathing and oxygen supply to the body.

[SOAP]

  • 2023-03-14 Radiation Oncolgoy
    • Imp: Low rectal cancer involving anal canal with bleeding, cT4bN1bM0, Stage: IIIC.
    • Plan: Pre-operative CCRT for 5040cGy/28 fx then OP
      • CT simulation on 2023/03/16, 14:30.
  • 2023-03-14 Hemato-Oncology
    • Port-A insertion
    • Arrange admission for FOLFOX on 2023-03-23
  • 2023-03-13 Colorectal Surgery
    • Suggest CCRT then OP (Laparoscopic APR ? due to sphincter invasion)

[radiotherapy]

[chemotherapy]

  • 2023-03-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.

  • For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.

  • The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.

  • The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).

  • The current active prescription has no identified issues.

701064531

230329

[exam findings]

  • 2023-02-10 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla. Dental problem may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-12-20 CT - abdomen
    • History and indication: ovary CA
    • IMP:
      • S/P operation.
      • A hypodense nodule (4.5mm) at S5-6 junction of liver.
  • 2022-12-12 SONO - kidney urology
    • Grossly normal, bilateral kidneys
  • 2022-12-09 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Borderline ECG
  • 2022-12-09 Gynecologic ultrasonography
    • ATH + BSO
    • Lt fluid
  • 2022-11-24, -11-21 KUB
    • S/P drainage tube in the pelvic cavity.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Non-specific bowel gas pattern.
  • 2022-11-16 Patho - uterus with or without SO non-neoplastic/prolapse
    • Diagnosis:
      • Ovary, right, oophorectomy —- Clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c1N0(if cM0); FIGO Stage: IC1
      • Ovary, left, oophorectomy —- Negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
      • Uterus, corpus, total hysterectomy —- Negative for malignancy
      • Uterus, endometrium, total hysterectomy —- Negative for malignancy
      • Uterus, cervix, total hysterectomy —- Negative for malignancy
      • Omentum, omentectomy —- Negative for malignancy
      • Lymph node, left iliac, dissection —- Negative for malignancy (0/1)
      • Lymph node, left obturator, dissection —- Negative for malignancy (0/3)
      • Lymph node, right iliac, dissection —- Negative for malignancy (0/3)
      • Lymph node, right obturator, dissection —- Negative for malignancy (0/9)
      • Lymph node, left para-aortic, dissection —- Negative for malignancy (0/8)
      • Lymph node, right para-aortic, dissection —- Negative for malignancy (0/5)
    • Gross description:
      • Procedure (select all that apply): Total hysterectomy, bilateral salpingo-oophorectomy, Omentectomy
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.]
        • Specimen Integrity of Right Ovary (if applicable): intra-op rupture
        • Specimen Integrity of Left Ovary (if applicable): Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Right ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size: Greatest dimension (centimeters): 7.0 cm
        • Additional dimensions (centimeters): 6.5 x 5.0 cm
      • Specimen size:
        • left ovary: 2.5 x 1.3 x 0.4 cm;
        • right tube: 5.0 cm in length and 0.3 cm in diameter;
        • left tube: 5.2 cm in length and 0.3 cm in diameter;
        • uterus: 7.0 x 5.1 x 4.0 cm, 88 gm; Cervix: 4.2 x 4.2 x 2.6 cm; Endometrial cavity: 3.2 x 2.0 x 0.2; A leiomyoma: 0.5 x 0.5 x 0.4 cm and adenomyosis are seen
      • Sections are taken and labeled as:
        • F2022-00542: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: fallopian tube; X2-6: ovary.
        • S2022-20256: A: lymph node, left iliac; B: lymph node, left obturator; C: lymph node, right iliac; D1-2: lymph node, right obturator; E: lymph node, left para-aortic; F: lymph node, right para-aortic; G1: cervix; G2: endometrium; G3: left ovary and fallopian tube; G4: leiomyoma; G5: right posterior wall; G6: right adnexa soft tissue; H: omentum.
    • Microscopic Description:
      • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), Napsin A(+), WT-1(-), p53(wild type), and PR(-).
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.): not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): not aplicable
      • Peritoneal/Ascitic Fluid: N2022-04209: Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: Negative for metastasis: please see diagnosis
      • Additional Pathologic Findings: A leiomyoma and adenomyosis are seen in uterus.
  • 2022-11-16 Frozen section
    • Preliminary diagnosis: Ovary, right, oophorectomy — adenocarcinoma
  • 2022-11-15 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric erosion, angularis
    • Suggestion
      • Pursue CLO test result
  • 2022-11-14 ECG
    • ICRBBB pattern
      • ChatGPT
        • ICRBBB stands for “Incomplete Right Bundle Branch Block” and refers to a specific pattern seen on an electrocardiogram (ECG). In a normal heart, electrical impulses travel through both the left and right bundle branches, allowing for coordinated contractions of the ventricles. In ICRBBB, the right bundle branch is delayed or blocked, causing a characteristic pattern on the ECG.
        • The ECG in ICRBBB typically shows a widened QRS complex (greater than 120 milliseconds) with a slurred or notched R wave in leads V1 and V2. There may also be ST segment and T wave changes in leads V1 to V3. ICRBBB is considered “incomplete” because the duration of the QRS complex is not as long as it would be in a complete right bundle branch block.
        • ICRBBB is often considered a benign finding and may be present in otherwise healthy individuals. However, it can also be associated with various underlying cardiac conditions, such as pulmonary embolism, right ventricular hypertrophy, and certain congenital heart defects. Further evaluation by a healthcare provider may be warranted in certain cases.
  • 2022-11-14 CTA - pelvis
    • Clinical history: 52 y/o female patient with s/p Chocolate cyst
      • L’t pelvic pain, constipation, Delking on 2022-11-16.
    • With and without contrast enhancement CT of abdomen–whole:
      • There is mulcystic tumor, 8.8x6.1cm in right adnexa, with solid and cystic component and septum, suspected right ovarian malignancy.
      • Liver cyst, 0.5cm in S7.
      • Fibrotic infiltrate in RUL.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • If proven ovarian malignancy
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia_(Stage_value)
  • 2022-11-08 Gynecologic ultrasonography
    • LT adnexae:free
    • endometrial (+fluid)
    • IMP: Suspected Rt Ovarian mass: (92mm x65mm), papillary:(40mm x31mm), RI: 0.35

[consultation]

  • 2022-12-13 Urology
    • Q
      • This 52 years old female, Right ovarian clear cell carcinoma, pStage IC, pT1c1N0cM0; FIGO Stage IC2 status post Debulking surgery on 2022/11/16 and s/p port-A insertion on 2022/11/25. According to the patient, she had intermittent chills and left flank soreness since 2 days ago. After admitted her vital signs were stable and no fever. The PE found no abdominal tenderness, wound clean and no CP angle knocking tenderness. The lab datas revealed no leukocytosis or pyuria, but elevated CRP upto 12.68 -> 20.5 mg/dL. We need your expertised for renal echo. Thanks a lot!
    • A
      • the patient complained of flank or low back pain trigger by walk
      • USK showed no hydronephroiss
      • Therefore, low back pain (ligament, fascia, intervertebral disc) may be another possible cause of pain

[surgical operation]

  • 2022-11-16
    • Diagnosis:
      • Right ovarian tumor, suspected malignancy
      • Frozen section: adenocarcinoma
    • Surgery:
      • Debulking surgery (ATH + BSO + BPLND)   - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, marked adhesion to the rectum
      • Adnexa:
        • LOV: capsule intact , smooth surface.
        • ROV: intra-op rupture(+)
        • Fallopian tube: bilateral grossly normal
      • CDS: adhesion (+)
      • Ascites: scanty
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: infracolic omentectomy was done.
    • Other
      • Estimated blood loss: 1000 ml
      • Blood transfusion: 2U
      • Complication: nil

[chemotherapy]

  • 2023-03-28 - paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W, paclitaxel 20% off due to PLT 88K/uL)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-03 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - paclitaxel 160mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - paclitaxel 160mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

[assessment]

  • The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).

    • 2023-03-28 WBC 3.01 x10^3/uL
    • 2023-03-10 WBC 1.89 x10^3/uL * previous chemo on 03/03 - 7 days
    • 2023-03-02 WBC 5.52 x10^3/uL
    • 2023-02-17 WBC 1.42 x10^3/uL * previous chemo on 02/09 - 7 days
    • 2023-02-08 WBC 4.19 x10^3/uL
    • 2023-01-20 WBC 2.06 x10^3/uL * previous chemo on 01/12 - 8 days
    • 2023-01-12 WBC 5.31 x10^3/uL
    • 2022-12-27 WBC 3.09 x10^3/uL
    • 2022-12-19 WBC 8.25 x10^3/uL
    • 2022-12-12 WBC 5.71 x10^3/uL
    • 2022-12-09 WBC 10.45 x10^3/uL
    • 2023-03-28 PLT 88 x10^3/uL * previous chemo on 03/03 - 25 days (not fully recovered yet)
    • 2023-03-10 PLT 24 x10^3/uL * previous chemo on 03/03 - 7 days
    • 2023-03-02 PLT 100 x10^3/uL
    • 2023-02-17 PLT 131 x10^3/uL
    • 2023-02-08 PLT 117 x10^3/uL
    • 2023-01-20 PLT 64 x10^3/uL * previous chemo on 01/12 - 8 days
    • 2023-01-12 PLT 75 x10^3/uL * previous chemo on 12/20 - 8 days
    • 2022-12-27 PLT 129 x10^3/uL
    • 2022-12-19 PLT 209 x10^3/uL
    • 2022-12-12 PLT 126 x10^3/uL
    • 2022-12-09 PLT 138 x10^3/uL
  • The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.

  • No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.

701241752

230329

[exam findings]

  • 2023-03-28 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower T- and upper L-spines, L4, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower T- and upper L-spines and L4 spine. Degenerative change may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-03-27 KUB
    • Hepatomegaly is suspected.
  • 2023-03-23 CT - abdomen
    • Findings
      • A tumor (5.3cm) in left breast with left chest wall invasion.
      • Multiple liver tumors. A LN (1.5cm) at left subphrenic region.
      • Small amount ascites.
      • Perineural cysts at sacrum.
    • IMP
      • Left breast cancer with left chest wall invasion, LN and liver metastases.
  • 2023-03-23 KUB
    • Focal small bowel ileus in left abdomen.
    • There are calcifications in the pelvic cavity, could be due to phleboliths.
  • 2020-07-01 Gynecologic ultrasonography
    • Suspected Lt Ovarian Cyst
  • 2020-06-17 Gynecologic ultrasonography
    • Endometrial thickening
    • Suspected bilateral ovarian cyst

[assessment]

  • 2023-03-29 FOBT 4+. A result of 4+ means that a significant amount of blood was detected in the sample, indicating a possible gastrointestinal bleeding. Takepron (lansoprazole) has been prescirbed (ST). Further evaluation and testing may be needed to determine the cause of the bleeding.

701356216

230329

[past history] - 2023-03-25 admission note

  • myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment.
  • hyperlipidemia
  • hepatitis B carrier with Baraclude since 2022/05.
  • gastric ulcer for 10+ years ago.

[allergy]

  • NKDA

[family history]

  • Father: HCC
  • Mother: Type II diabetes mellitus

[exam findings]

  • 2023-03-28 CXR
    • Bilateral pleura effusion.
    • S/P pigtail catheter implantation at right CP angle.
  • 2023-03-27 L-spine AP + Lat. (including sacrum)
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
  • 2023-03-27 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-27 Hand Lt
    • S/P total amputation of 3rd distal phalanx and middle phalanx, and partial amputation of 3rd proximal phalanx of Left hand.
    • S/P near total amputation of 2nd distal phalanx of Left hand.
    • Angulation deformity of 2nd PIP joint.
  • 2023-03-27 C-spine AP + Lat
    • Small Nuchal ligament calcification over the posterior neck
  • 2023-03-27 Spirometry
    • Mild reduction of total lung capacity
    • Moderate restrictive ventilatory impairment, Not significant bronchodilator reversibility
    • Moderate reduction of diffusion capacity
  • 2023-03-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 26) / 102 = 74.51%
      • 2D (M-simpson) = 75
    • Conclusion
      • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
      • Preserved LV and RV systolic function.
      • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
      • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
      • Some R’t plerual effusion.
  • 2022-04-18 SONO - abdomen
    • Calcified spot, 0.45cm in right lobe liver.
    • Suspected minimal ascites in subphrenic region, right.
  • 2022-04-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 26) / 120 = 78.33%
      • 2D (M-simpson) = 78
    • Conclusion
      • Septal and RV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR.
  • 2022-03-30 Spirometry
    • Normal baseline without significant reversibility
    • FEV1FVC=91.41%, FVC= 87%, FEV1= 98%
    • normal total lung capacity TLC=101%
    • suspect mild air trapping, RV/TLC=42.07%
    • normal diffusion capacity
  • 2022-03-16 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Plasma cell myeloma
    • Microscopically, it shows hypercellularity with hemopoietic components accounting for about 70% of the marrow space, and M/E ration of 2: 1. of the bone marrow space. Plasma cells are increased (> 10%) and highlighted by CD138. Occasional megakaryocytes are seen.
    • Immunohistochemical stain reveals CD34(-), CD117(-), MPO(+), CD71(+), CD20(focal +, < 5%), Kappa light chain(-), Lambda ligh chain (+ for monoclonality).
    • ADDENDUM: Special stain — congo red (+), compatible with amyloidosis
  • 2022-03-07 Surgical pathology Level IV
    • PATHOLOGICAL DIAGNOSIS:
      • Kidney, needle biopsy for light microscopic examination — Compatible with amyloidosis (lambda light chain type) — Mild arteriosclerosis
      • COMMENT: We are limited in our assessment because the specimen submitted for light microscopy contains renal medullary tissue only. No glomerulus is available. The semithin sections prepared for electron microscopic examination show glomeruli with mesangial expansion. By immunofluorescence, the lambda staining is stronger than kappa in the glomerular mesangium and capillary walls. The electron microscopy demonstrates the presence of randomly oriented fibrils 8-12 nm in diameter within the mesangium and along the glomerular basement membranes. Although the Congo red staining is not contributory, the above features are mostly compatible with renal involvement by amyloidosis. Clinical correlation is recommended. For EM findings, please see report S111-80825.
  • 2022-03-07 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Prolonged QT
  • 2022-02-23 SONO -nephrology
    • chronic parenchymal renal disease
    • right renal cyst

[consultation]

  • 2023-03-29 Neurology
    • Q
      • for bilateral last of three fingers numbness, and fall down repeatedly.
      • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
      • This time, he is admitted for Auto HSC collection, then he suffered from bilateral last of three fingers numbness, and fall down repeatedly, and the heart echo showed suspected non-bacterial thrombotic endocarditis. So we need your help, thanks a lot!!
    • A
      • hands weakness esp. at bilateral ulnar sides after the fall
      • NE: aware, fluent speech, bil. hearing impairment, no visual field defect, no facial weakness or tongue deviation, bil. Benedict hands and diffuse hypo-reflexia
      • Impression:
        • ulnar neuropathies, suspect entrapment neuropathy
        • amyloidosis
      • Suggest:
        • C-spine MRI, nerve conduction study and BAEP might be arranged
        • I would like to follow up this patient. Thank you for your consultation.
  • 2023-03-27 Cardiology
    • Q
      • for heart function evaluation, hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL
      • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
      • This time, he is admitted for Auto HSC collection, then he suffered from pitting edema 4+ at limbs,and the blood pressure lower (SBP: 70-90mmHg), CXR: bilateral pleural effusion, the lab of cardio enyzam poor (hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL), 12-Lead EKG: Normal sinus rhythm, Left axis deviation, Low voltage QRS, Cannot rule out Anteroseptal infarct, age. The heart echo will be arranged. So we need your help, thanks a lot!!
    • A
      • S
        • 55 year-old male had the history of Myeloma with Amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy and lab test. start chemotherapy with Velcade TD from 20220506
      • O
        • LAB NTproBNP 8184 hsTnI167.9 CKMB 6.1 Cre 0.83 ALT 32 albumin 2.2 Hb 13.5 WBC 25960 PLT 219k band 6.8%
        • echocardiogram 20230327
          • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
          • Preserved LV and RV systolic function.
          • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
          • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
          • Some R’t plerual effusion.
        • CXR 20230327 right pleural effusion 20230307 clear lung field
        • ECG 20230327 sinus rhythm, low voltage, left axis deviation
      • Impression
        • Hypertrophic cardiomyopathy, suspected amyloidosis related
        • Oscillating lesions on mitral and tricuspid valves, nature?; with mild MR and TR
        • Severe hypoalbuminemia
      • Suggestion
        • Collecting blood cultures x3 to exclude bacterial endocarditis
        • Correct hypoalbuminemia
        • Right pleural effusion study
        • By echocardiogram, IVC 13mm suggested low intra-vascular volume
        • Check adrenal and thyroid function; may give midodrine for BP support

[SOAP]

  • 2023-02-24 Hemato-Oncology
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923, C5W2 20220930, C6W1 20221014, C6W2 20221021, C7W1 20221104, C7W2 20221111, C8W1 20221202, C8W2 20221209, C9W1 20221223, C9W2 20221230. C10W1 20230113, C10 W2 20230120, C11W1 20230203, C11W220230210 )
    • admission at March 25, prepare for GCSF injection at March 26-30, Auto HSC collection at March 30-31.
  • 2022-09-23 Hemato-Oncology
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923)
    • Dara not approved by NHI
    • continue VTD therapy C5
  • 2022-09-09 Hemato-Oncology
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI (approved)
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722)
    • apply for Velcade and daraturamab
  • 2022-04-20 Hemato-Oncology
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI (approved)
    • apply for velcade
    • start steroid therapy and vemlidy
  • 2022-03-30 Hemato-Oncology
    • P
      • check light chain and beta2-microglogulinemia
      • check bone marrow (plasma cell myeoloma)
      • apply for Major disease to NHI
  • 2022-03-16 Hemato-Oncology
    • P
      • check light chain and beta2-microglogulinemia
      • check bone marrow
  • 2022-03-16 Nephrology
    • P: refer to Hema OPD due to amyloidosis (lambda light chain type)

[chemotherapy]

  • 2023-02-10 - bortezomib 1.3mg/m2 2.47mg SC 5min D1,5
  • 2023-02-03 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2023-01-20 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2023-01-13 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2022-12-30 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
  • 2022-12-23 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
  • 2022-12-09 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-12-02 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-11-11 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-11-04 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-10-21 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-10-14 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-09-30 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-09-23 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-22 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-15 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-01 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-06-24 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-06-10 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-27 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-13 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-04 - bortezomib 1.3mg/m2 2.39mg SC 5min D1,5

[medication]

  • 2022-05-04 ~ 2023-03-17 - Thado (thalidomide 50mg) 1# HS

[assessment]

  • The patient was admitted for planned HSC harvest, but bilateral numbness in the last three fingers and elevated cardiac enzymes were observed, so further studies are being conducted.
  • There is no issue with the active recipe being used.

700753896

230328

[diagnosis] - 2023-03-27 admission note

  • Squamous cell carcinoma of upper third of esophagus, cT3N1M0, stage II status post feeding jejunostomy and left port-A implantation on 2023/02/20 and concurrent chemoradiotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2 x4 days) from 2023/02/27~
  • Gastro-esophageal reflux disease without esophagitis
  • Hypertensive heart disease without heart failure
  • Constipation, unspecified
  • Cachexia
  • Insomnia, unspecified
  • Hypomagnesemia

[exam findings]

  • 2023-03-03 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
  • 2023-02-22 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 10 dB HL, WNL
      • L’t : 13 dB HL, normal to mild SNHL.
  • 2023-02-20 CXR
    • widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • 2023-02-18 MRI - brain
    • no evidence of brain tumors.
  • 2023-02-17 SONO - abdomen
    • suspected liver calcification, left
    • suspected GB stones
  • 2023-02-16 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, lower L-spines, right S-I joint, bilateral shoulders, hips and left knee in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower L-spines and right S-I joint. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips and left knee, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2023-02-15 Bronchoscopy
    • no endotreacheal or endobronchial lesions
  • 2023-02-14 Whole body PET scan
    • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 284 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
    • There was increased FDG uptake in a focal area in the proximal portion of the esophagus (SUVmax early: 17.72, delay: 22.73) and in bilateral shoulders (SUVmax early: 3.37, delay: 1.72). In addition, there was increased FDG accumulation in both kidneys and bilateral ureters.
    • IMPRESSION:
      • A glucose hypermetabolic lesion in the proximal portion of the esophagus, compatible with primary esophageal malignancy.
      • Mild glucose hypermetabolism in bilateral shoulders. Arthritis may show this picture.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-02-13 CXR
    • Widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Minimal dextroscoliosis of the T-spine
  • 2023-02-03 CT - chest
    • Indication: esophageal inlet mucosal lesion, pending patho. suspected esophageal cancer, for staging
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Submucosa soft tissue mass at upper third esophagus measuring 2.49cm is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP, but small lymph nodes (n=2) are found at paraesophageal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp: Esophageal submucosa tumor, 2.49cm.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-02-03 Patho - esophageal biopsy
    • Esophageal tumor, 16 cm below the incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the fibrotic stroma.
    • Immunohistochemical stains of CK5/6(+), P16(-) and P63 (+) for tumor.
  • 2023-02-02 Esophagogastroduodenoscopy, EGD
    • Suspected esophageal malignancy, L/3, s/p biopsy*4
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • 2022-07-22 Nasopharyngoscopy
    • suspected acute thyroiditis
  • 2021-11-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (86.3 - 17.7) / 86.3 = 79.49%
      • M-mode (Teichholz) = 79.5
    • Normal AV/MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size

[consultation]

  • 2023-02-20 Hemato-Oncology
    • A
      • We are consulted for CCRT.
      • Please check 24 urine CCR, auditory test, HbsAg, AntiHbc, Anti HCV. Arrnage our OPD after discharge.
  • 2023-02-17 Radiation Oncology
    • A
      • CCRT is indicated.
      • CT-simulation will be arranged on 2/22.
      • Plan to deliver 45 Gy/ 25 fx to the upper 2/3 esophagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 2/27.
  • 2023-02-14 Gastroenterology
    • Q
      • This 76-year-old woman denied any systemic disease. She has suffered from dysphagia for solid material with odynophagia for 2 months, associated with weight loss 7 kg in 6 months. She has visited our GI OPD, where PES revealed suspected esophageal malignancy S/P biopsy was done. Chest CT showed esophageal submucosa tumor, 2.49cm. suspected GIST. For this newly diagnosed esophageal cancer, she was admitted for cancer work-up.
      • Thus we need consult you for arrange EUS and abdominal ultrasound. Thank you very much.
      • schedule
        • 112/02/14 10:30 PET scan
        • 112/02/15 bronchoscope
        • 112/02/16 11:00 bone scan
        • 112/02/18 08:40 brain MRI
        • hope to arrange the examination before 112/02/17.
    • A
      • For EUS:
        • Miniprobe EUS is technically challenging and NOT recommended due to the position of the lesion.
        • Please consider other diagnostic/staging modality
      • For abd echo:
        • Already arrange abdominal echo on 0217.

[surgical operation]

  • 2023-02-20
    • Surgery
      • Feeding jejunostomy + port-A
    • Finding
      • 18 Fr. silicon Foley catheter as jejunostomy tube
      • 8.0 Fro. Polysite, left cephalic vein, cut-down method.
  • 2022-11-15
    • Surgery: Hemorrhoidectomy        
    • Finding: Prolasped hemorrhoids at 3,7,11 o’clock
  • 2021-09-23
    • Surgery: lt PF MIS lateral release
      • The patient underwent a lateral release of the lateral patellofemoral ligament using minimally invasive surgery techniques.
    • Finding: PF OA PFPS
      • The patient has patellofemoral osteoarthritis (PF OA) and patellofemoral pain syndrome (PFPS), which are conditions that affect the knee joint. The lateral release surgery was likely performed to address these conditions, as it can be used to alleviate pain and improve the alignment of the patella.
  • 2019-09-23
    • Diagnosis: left knee osteoarthritis
    • PCS code: 64164B
  • 2018-09-03
    • Diagnosis: rt OA knee
    • PCS code: 64164B

[chemotherapy]

  • 2023-03-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
  • 2023-02-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

==========

2023-03-28

  • On 2023-03-22, the patient had a BUN/serum creatinine ratio of 31. The normal ratio is 10 to 15:1 but can be greater than 20:1 in prerenal disease due to the increased passive reabsorption of urea that follows the enhanced proximal reabsorption of sodium and water. This selective rise in BUN is known as prerenal azotemia. The serum creatinine concentration will increase in this setting only if the degree of hypovolemia is severe enough to lower the GFR. Therefore, it is recommended to rule out hypovolemia or upper gastrointestinal bleeding as possible causes for the elevated BUN/serum creatinine ratio.
    • 2023-03-22 BUN 29 mg/dL
    • 2023-02-27 BUN 13 mg/dL
    • 2023-02-13 BUN 11 mg/dL
    • 2022-11-14 BUN 9 mg/dL
    • 2023-03-22 Creatinine 0.94 mg/dL
    • 2023-02-27 Creatinine 0.60 mg/dL
    • 2023-02-13 Creatinine 0.71 mg/dL
    • 2022-11-14 Creatinine 0.59 mg/dL

2023-03-01

  • The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.

  • Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.

700947307

230328

[diagnosis] - 2023-03-27 admission note

  • Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel status post 3 dimensions single incision laparoscopic right hemicolectomy with laparoscopic adhesion lysis and resection of small bowel on 2021/12/01
  • Metastatic uterine adenocarcinoma status psot Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy on 2021/12/01
  • Hepatitis B carrier

[past history]

  • The patient is B hepatitis carrier
  • history of operation:
    • Status post Caesarean section about 40 years ago
    • Status post Tympanoplasty on 2011/04/19
    • Right renal stone status post extracorporeal shock wave lithotripsy on 2009/04/15
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid): OK。
  • Regular medications or herb:no                                                                     

[allergy]

  • NKDA                                                             

[family history]

  • Father had liver cancer
  • Mom had diabetes mellitus type 2 and hypertension

[exam findings]

  • 2023-03-27 KUB
    • S/P metalic autosuture and few clips projecting at right lower abdomen.
    • Fecal material store in the colon.
  • 2023-02-09 All-RAS + BRAF mutations assay
    • ALL-RAS:
      • Detected (KRAS codon 12 GGT>GTT, p.G12V)
    • BRAF
      • There was no variant detect in the BRAF gene.
  • 2023-02-08 CT - abdomen
    • History: cecal CA wt terminal ileum invasion (T4b), lung, liver, uterus mets (M1b), pT4bN2aM1b; stage IVB,
    • Indication: multiple lung metastases
    • Findings:
      • There is a newly-developed lobulated enhancing soft tissue mass 1.3 cm in right middle pelvis with direct invasion right L/3 ureter causing moderate hydroureteronephrosis but no delayed contrast excretion of right kidney.
        • Metastasis in right middle pelvis induce obstructive uropathy is highly suspected.
        • In addition, There is a newly-developed lobulated enhancing soft tissue mass 3.2 cm in right uterine fossa that is also c/w tumor recurrence.
      • There are at least seven newly-developed soft tissue nodules in right lower omentum that are c/w tumor seeding.
      • There are several newly-developed metastatic nodes in para-aortic space and para-cava space .
      • Prior CT identified Multiple metastase in bil. lungs are noted again, increasing in size and number that is c/w progressive disease.
      • S/P right hemicolectomy and S/P hysterectomy
      • Right renal stone (5mm).
      • Tiny gallbladder stones.
    • Impression:
      • Two metastases or local recurrent tumor in right middle pelvis and right uterine fossa.
      • Seven tumor seeding in right lower omentum.
      • Metastatic nodes in para-aortic space and para-cava space
      • Multiple lung metastases show progressive disease.
  • 2022-10-04 CT - chest
    • Indication
      • Secondary malignant neoplasm of right lung
      • Malignant neoplasm of cecum
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Several nodular lesions are found at both lungs with some of them shows cavitation. Recurrent/residual metatsatic lung nodules are considered.
          • In comparison with CT dated on 2022-07-25, the numbers of the lesions increased.
        • S/p port-A placement with its tip at Superior vena cava.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Tiny low density lesion at S6/7 of liver is found. Suspected liver meta.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Bilaeral lung meta. In progression.
      • Suspected liver meta.
  • 2022-07-26 Patho - lung transbronchial biopsy
    • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differetiated, consistent with metastatic colorectal orgin
    • Sections show cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CDX2(+) and TTF-1(-).
    • The results are consistent with metastatic colorectal adenocarcinoma.
  • 2022-07-25 CXR
    • a ndular lesion with extensive ground glass opacity over Rt upper lobe s/p cryoablation
    • recticular opacities over both lower lung zones
  • 2022-07-25 Right Lower Lobe Lung Mets Cryotherapy
    • Indication: right lower lobe lung meta
    • Position: Prone
    • Cryotherapy was done with cryoneedles placed into right lower lobe lung tumor region. One session of cryotherap with 3-7-10 minutes of cryotherapy was done. Iceball was visualized with total coverage of the tumor.
  • 2022-07-05 CT - abdomen
    • History and indication: cecal cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Cecal cancer s/p operation.
      • Multiple nodules in bil. lungs.
      • Right renal stone (4mm).
      • Tiny gallbladder stones.
    • IMP:
      • Cecal cancer s/p operation.
      • Multiple nodules in bil. lungs c/w metastases.
  • 2022-06-26 Colonoscopy
    • Diagnosis
      • C/W post right hemicolectomy, no evidence of cancer recurrence.
      • Internal hemorrhoid
    • Suggestion
      • OPD F/U
    • Complication
      • No immediate complication
  • 2022-05-17 CT - abdomen
    • Cecal cancer s/p operation.
    • Multiple nodules in bil. lungs suspected metastases.
  • 2021-12-28 CT - chest
    • Indication: colon cancer with liver & lung mets
    • Comparison made with previous CT dated on 2021/11/29 abdominal CT.
      • lungs:
        • multiple numerous nodules of variable sizes in both lungs (up to 8.2 mm at RLL), consistent wth metastatic lesions
      • Mediastinum: no enlarged LN or mass.
      • Hila: unremarkable.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall: unremarkable.
      • Visible abdominal-pelvic contents:
        • a metastitc hepatic tumor 23 mm in S7.
        • several small bilateral renal cysts.
        • unremarkable of the spleen, adrenal glands, pancreas, and gall baldder.
        • no enlarged lymph node or ascites.
        • s/p Rt hemicolectomy with retained surgical clips.
      • Visualized bones: unremarkable.
    • Impression:
      • colon ca s/p with multiple lung metastatic tumors and solitary hepatic metastatic tumor.
  • 2021-12-02 Patho - uterus with or without SO non-neoplastic/prolapse
    • DIAGNOSIS:
      • Uterus, myometrium, laparoscopic hysterectomy — Metastatic adenocarcinoma, compatible with colorectal origin — Intramural leiomyoma
      • Uterus, endometrium, laparoscopic hysterectomy — Postmenopausal state.
      • Uterus, cervix, laparoscopic hysterectomy — Negative for malignancy
      • Adnexae, bilateral, salpingo-oophorectomy — Negative for malignancy
    • Microscopically, the myometrium shows metastatic adenocarcinoma composed of invasive neoplastic glands
  • 2021-12-02 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal — Free
      • Terminal ileum — Involved by adenocarcinoma
      • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (4/12)
      • Labeled posterior abdominal wall — Involved by adenocarcinoma
      • Pathology stage: pT4bN2aM1a; AJCC stage IVA
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
  • 2021-11-29 CT - abdomen
    • Impression:
      • Cecal tumor, with extension to appendix and terminal ileum, and lymphadenopathy at right lower quadrant. Malignancy is highly suspected.
      • A 5.4cm uterine tumor, suspect malignancy. Suggest GYN ultrasound correlation.
      • RLL pulmonary nodule.
      • Mild ascites.
      • Bilateral renal cysts. Right renal stone.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:4b(T_value) N:2a(N_value) M:1a(M_value) STAGE:IV(Stage_value)
  • 2021-11-29 Gynecologic Ultrasonography
    • RT adnexae: free
    • IMP : Uterine mass: (1) 45x38mm, (2) 21x18mm

[surigcal operation]

  • 2021-12-01
    • Surgery
      • Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy
    • Finding
      • Uterus: enlarged, 11x6x3cm, corpus – right posterior uterine mass 6x5cm with iiregular border, primary uterine tumor or colon cancer metastasis?
      • border adhesion to right pelvic wall, tumor adhesion?
      • another small myomas 2~3# 2cm for each
      • EM – np
      • cervix eroded
      • bil adnexa: normal-looking
      • CDS: some pelvic adhesion (due to previous cesarean section and tumor asdhesion>?) were noted between ant peritoneum and bladder; between post uterus, right pelvic wall and bowels s/p laparoscopic lysis
  • 2021-12-01
    • Surgery
      • 3D SILS right hemicolectomy + laparoscopic adhesion lysis + resection of small bowel      
    • Finding
      • Lower abdomen adhesion due to previous C/S Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel

[chemoimmunotherapy]

  • 2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-07 (Avastin + FOLFOX)

  • 2023-01-09 (Avastin + FOLFOX)

  • 2022-12-12 (Avastin + FOLFOX)

  • 2022-11-18 (Avastin + FOLFOX)

  • 2022-10-26 (Avastin + FOLFOX)

  • 2022-07-04 (Avastin + FOLFIRI)

  • 2022-06-08 (Avastin + FOLFIRI)

  • 2022-05-16 (Avastin + FOLFIRI)

  • 2022-04-20 (Avastin + FOLFIRI)

  • 2022-03-29 (Avastin + FOLFIRI)

  • 2022-03-04 (Avastin + FOLFIRI)

  • 2022-02-11 (Avastin + FOLFIRI)

  • 2022-01-12 (Avastin + FOLFIRI)

  • 2021-12-27 (Avastin + FOLFIRI)

[assessment]

  • On 2021-12-01, the patient underwent surgery for cecal cancer with terminal ileum invasion and metastases to the lung, liver, and uterus, resulting in a diagnosis of pT4bN2aM1b, stage IVB. The surgery involved a 3D SILS right hemicolectomy with laparoscopic adhesion lysis and resection of the small bowel, as well as a laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy. The patient then received Avastin + FOLFIRI from 2021-12-27 to 2022-07-04, and Avastin + FOLFOX from 2022-10-26 to 2023-02-07.
  • On 2023-02-08, a CT scan showed two metastases or a local recurrent tumor in the right middle pelvis and right uterine fossa, seven tumor seedings in the right lower omentum, and metastatic nodes in the para-aortic space and para-cava space, as well as multiple lung metastases showing progressive disease. Consequently, the patient’s regimen was changed to FOLFOXIRI from 2023-03-01 and the treatment is ongoing.
  • On 2023-02-09, a KRAS mutation was identified in the patient’s tumor (codon 12 GGT>GTT, p.G12V), which suggests that certain targeted therapies, including anti-EGFR therapies such as cetuximab or panitumumab, are unlikely to be effective. Patients with KRAS mutations are typically not eligible for these treatments.
  • The patient has received the 2nd cycle of FOLFOXIRI during this hospital stay, and it is too early to determine its effectiveness. There have been no severe adverse reactions related to the treatment so far.
  • Based on the patient’s prescription records in the PharmaCloud database for the last 3 months, there are no issues with medication reconciliation.

701027894

230328

[diagnosis] - 2023-03-28 discharge note

  • Malignant neoplasm of endometrium
  • Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Hypomagnesemia
  • Anemia due to antineoplastic chemotherapy

[exam findings]

  • 2023-03-03 Mammography
    • Old mammographic study: 2021-04-15 (BIRADS 1)
    • Digital mammography of both breasts with MLO and CC views:
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There is no obvious mass lesion.
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative.-annual screening.
  • 2022-11-23 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-10-27 CT - abdomen
    • History and indication: Endometrial cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Swelling of anterior abdominal wall. A LN (1.5cm) at left paraaortic region. Small LNs at bil. inguinal regions.
      • Grade 4 fatty liver.
      • Left renal cyst (5mm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P hysterectomy.
      • Swelling of anterior abdominal wall. A LN at left paraaortic region.
  • 2022-10-27 ENT Hearing Test
    • PTA
    • Reliability FAIR
    • Average RE 19 dB HL; LE 23 dB HL.
    • Bil WNL.
  • 2022-10-01 CT - chest
    • Indication: GYN cancer, suspected metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Linear atelectatic change at right lower lobe is found.
        • Subpleural nodule at left upper lobe up to 0.4cm in largest dimension is found. (Se8 Im44).
        • Non-specific lymph nodes are found at right hilar and left paratracheal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Marked fatty liver is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Compatible with endometrial cancer s/p C/T, No definte lung meta but non-specific lymph nodes in the mediastinum. Suggest follow up.
  • 2022-09-26 Patho - uterus with or without SO
    • pathologic diagnosis
      • Uterus, endometrium, staging surgery — Endometroid carcinoma
      • Fallopian tube, right, BSO — Endometriosis with atypical hyperplasia
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic carcinoma (8/35)
      • AJCC 8 th edition, Pathology stage: pT1bN1a; stage IIIC1; FIGO stage IIIC1
    • macroscopic examination
      • Procedure: LAVH + BSO + partial omentectomy + BPLND + para-aortic LN dissection
      • Specimen Size: 15 x 11 x 7.0 cm and 430 gm (uterus), 2.5 x 1.4 cm (Rt ovary), 5.2 x 1.0 cm (Rt tube), 2.2 x 1.5 cm (Lt ovary), 5.0 x 1.2 cm (Lt tube), and 25 x 12 x 5.0 cm (omentum)
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium, diffuse
      • Tumor Size: 7.5 x 5.6 x 2.8 cm
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic LNs
      • Representative parts are taken for section and labeled as: A= left iliac LNs, B1-B4= left obturator LNs, C= right iliac LNs, D1-D2= right obturator LNs, E= left para-aoric LNs, F1-F2= right para-aortic LNs, G1-G4= cerivx, G5-G8= endometrial tumor, G9-G10= right ovary and fallopian tube, G11-G12= left ovary and fallopian tube, H1-H2= omentum
    • microscopic examination
      • Histologic Type: Endometroid carcinoma
      • Histologic Grade: FIGO grade 2
      • Adenomyosis: Present
      • Uterine Serosal Involvement: Not identified
      • Cervical Stromal Involvement: Not identified
      • Other Tissue/Organ Involvement: Not applicable
      • Peritoneal/Ascitic Fluid: Negative
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1.5 cm
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: Metastatic carcinoma (8/35)
        • number of lymph node examined: 3 (left iliac), 11 (left obturator), 4 (right iliac), 10 (right obturator), 2 (left para-aortic), and 5 (right para-aortic)
        • number with metastases >2 mm: 4 (left obturator), 4 (right obturator)
        • number with metastases <=2 mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1b (tumor invading one-half or more of the myometrium)
        • Regional Lymph Nodes: pN1a (regional lymph node metastasis(> 2mm) to pelvic lymph nodes)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIC1
      • AdditionalPathologic Findings
        • Cervix: Chronic cervicitis with Nabothian cyst and squamous metaplasia
        • Myometrium: Adenomyosis
        • Ovary, right: Unremarkable
        • Ovary, left: Endometriosis
        • Fallopian tube, right: Endometriosis with atypical hyperplasia
        • Fallopian tube, left: Endometriosis
        • Omentum: No remarkable change
  • 2022-09-21 MRI - pelvis
    • Clinical history: 47 y/o female patient with 2022/09/14 PATHO-endometrium curretage/biopsy, DIAGNOSIS: Uterus, endometrium, TCR — Endometrioid carcinoma.
    • With and without contrast enhancement MRI: Pelvis (Sag T2, axial T1, T2 and T1FS, coronal T2, post contrast enhancement axial and coronal T1FS, upper abdomen survey)
      • There are diffuse soft tissue tumors in the uterine cavity, suspected endometrial malignancy.
      • Tubular cystic lesion in right adnexa, suggesting hydrosalpinx.
      • Cysts in the uterine cervix, suggesting Nabothin cysts.
      • Unremarkable change of the liver, spleen, pancreas.
      • There are multiple enlarged lymph nodes in bilateral obturator region, internal and common iliac regions. Could be due to metastatic lymph nodes.
      • Non-enhancing nodule in left kidney, 0.45cm, suspected left renal cyst.
      • No ascites.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIC1____(Stage_value)
  • 2022-09-14 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, TCR — Endometrioid carcinoma
    • Specimen submitted in formalin consists of multiple pieces of red, irregular tissue measuring up to 3.2 x 1.4 x 0.5 cm. All for section in 5 cassettes A1-5.
    • Sections show pieces of blood clots and endometrial tissue with solid and cribriform glands. Moderate to severe nuclear atypia and frequent mitoses are seen.
  • 2022-09-09 Gynecologic ultrasonography
    • LT adnexae: free
    • Endometrial thickening (RI:0.15)
    • Rt Ovarian cyst suspected hydrosalpinx

[consultation]

  • 2022-11-28 Radiation Oncology
    • Q
      • This 47-year-old woman patient is a case of Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy.
      • This time, for severe nausea with vomiting after concurrent chemoradiotherapy. Now, for follow up. Thank you.
    • A
      • This 47 Y/O female has received adjuvant CCRT since 2022/10/24. She suffers from grade 2 nausea and vomiting during CCRT, although self-paid Emend has been prescribed.
      • RT dose: 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics, 2022/10/24 to 11/28.
      • Concurrent weekly cisplatin: 10/29, 11/04, 11/11, 11/18, 11/25.
      • RT side effects, 11/28: Radiation dermatitis, grade 0; nausea, grade 2; enteritis, grade 1; proctitis, grade 1; cystitis, grade 0.

[surgical operation]

  • 2022-09-26
    • Surgery
      • Diagnosis
        • Pelvic MRI on 09/21 showed Diffuse soft tissue in the uterus with multiple enlarged pelvic lymph nodes, suspected endometrial malignancy, cstage T1bN1aM0, IIIC1.
        • Endometrial cancer
      • Operation
        • Laparoscopic gynecologic oncology staging surgery  
        • change to exploratory laparoscopy + laparotomy (ope) gynecologic oncology staging surgery (BPLND and bilateral para-aortic lymphadenectomy)    
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: severe adhesion, s/p adhesiolysis
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • CDS: ascites (+)
    • Others
      • Estimated blood loss: 300ml
      • Blood transfusion: nil
      • Complication: nil  
  • 2022-09-26
    • Surgery
      • Operation
        • Adhesionolysis
    • Finding
      • s/p lower midline incision with periumbilical hernia
      • severe adhesion of omentum and small bowel in lower peritoneal cavity
  • 2022-09-14
    • Surgery
      • TCR, for endometrial thickening.
      • with D&C      
    • Finding
      • Endometrial thickening, occupying the whole uterine cavity, suspected endometrial hyperplasia.
      • Bilateral ostium: difficult to see.
      • Usage of dextrose water: 1000ml/900 ml.
      • Estimated bloodloss: 10 ml;
      • Blood Transfusion: nil; Complication: nil.  

[radiotherapy]

  • 2022-10-24 ~ 2022-11-28 - 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics

[chemotherapy]

  • 2023-03-27 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - paclitaxel 140mg/m2 240mg NS 500mL 3hr + carboplatin AUC 5 450mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-24 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + magnesium sulfate 10% 20mL 1hr + aprepitant 125mg D1-3
  • 2022-11-17 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-10 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-03 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-10-28 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg D1-3

==========

2023-03-28

  • The patient’s hypomagnesemia, which has been ongoing since November 2022, continues to persist (2023-03-23 serum Mg 1.7mg/dL). It is recommended to include magnesium supplements in the patient’s discharge plan.

2023-01-16

  • The hypomagnesemia observed since Nov 2022 might be related to the cisplatin administered as part of the CCRT in early October and November 2022. Creatinine levels rose from roughly 0.6 mg/dL in late September 2022 to 1.0 mg/dL in late November 2022. Hypomagnesemia due to urinary magnesium wasting can occur in over one-half of cases of cisplatin-induced nephrotoxicity. Magnesium supplements have been prescribed for the patient both orally (MgO) and intravenously (MgSO4).
  • Since the end of December 2022, no further hypocalcemia has been observed.
  • At this hospitalization, there have been no symptoms of nausea or vomiting observed (as a result of concurrent chemotherapy and radiotherapy, the patient experienced severe nausea and vomiting in late November 2022).

701320413

230328

{Chronic myelomonocytic leukemia, CMMoL}

  • diagnosis
    • 2022-10-19 adminsion note
      • Anemia, unspecified
      • Chronic myelomonocytic leukemia not having achieved remission
      • Unspecified viral hepatitis B without hepatic coma
      • Type 2 diabetes mellitus without complications
      • Chronic myeloproliferative disease
  • exam finding
    • 2022-11-19 Skull, Pelvis, Femur
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • 2022-11-18 Abdomen
      • Eqivocal osteoblastic change of the L-spine are suspected. please correlate with clinical condition or CT.
      • Splenomegaly is highly suspected.
    • 2022-10-21 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 19) / 84 = 77.38%
        • M-mode (Teichholz) = 77
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA
      • Mild MR, TR
    • 2022-10-20 Bronchodilator Test
      • normal ventilation, non-significant bronchodilator response
    • 2022-10-19 Abdomen, standing (diaphragm)
      • Eqivocal osteoblastic change of the L-spine are suspected.
      • Splenomegaly is highly suspected.
    • 2022-09-07 Cardiac Catheter
      • In conclusion
        • Coronary artery disease, tripple vessel disease, with stage PCI to right coronary artery, long diffuse stenosis with 86 % stenosis lesion in RCA-P with 83% stenosis in RCA-M.
        • S/P PTCA to RCA-P, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 4.0 X 38 mm), self expense, successful, from 86% stenosis reduced to 0% residual stenosis.
        • S/P PTCA to RCA-M, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 3.5 X 33 mm), successful, from 83% stenosis reduced to 11% residual stenosis.
      • Recommendation
        • Keep DAPT (dual antiplatelet therapy).
    • 2022-08-12 Cardiac Catheter
      • In conclusion :
        • Coronary artery disease, triple vessel diseases, with a A 74% stenosis lesion in LAD-P to LAD-M, A 72% stenosis lesion in LCx and A 85% stenosis lesion in RCA-M.
        • S/P PTCA to LAD-P to LAD-M, Drug eluting stent (Abbott Xience. 3.0 X 48 mm), successful, from 74% stenosis lesion reduced to 4% residual stenosis.
        • S/P PTCA to LCX, Drug eluting stent, (: Abbott Xience. 3.5 X 15 mm), successful, from 72% stenosis lesion reduced to 10% residual stenosis lesion.
      • Recommendation
        • Continue DAPT (dual antiplatelet therapy).
        • Stage PCI for RCA-M later.
    • 2022-07-25 Cardiac Catheter
      • Syntax Score = 22
      • In conclusion: CAD TVD
      • Recommendation: Due the comorbidity of pancytopenia, stem cell transplantation need revascularization earlier, will discuss with the patient and family for further management about CABG or PCI.
      • Left Ventriculogram: Normal LV size and LV wall motion, no MR, LVEF = 66%
      • Left Main: Patent
      • Left Anterior Descending: 80% stenosis ovre proximal LAD and 70% stenosis over mid LAD
      • Left Circumflex: 80% stenosis over proximal LCX and 70% stenosis over mid LCX
      • Right Coronary: diffuse atherosclerosis with 70% stenosis and 90% tandem lesions at mid RCA
    • 2022-07-19 CT - coronary artery calcium score, without contrast
      • Indication: a case of CKD and suspected CAD with chest pain, Hb 6.4
      • Findings
        • Extensive calcification of coronary arteries. LAD:419 LCX:302 RCA:187 total calcium score=908 (Agatston)
        • Unremarkable of the pericardium.
        • Normal size of cardiac chambers.
        • Mild calcified atherosclerosis of the thoracic aorta
      • Impression:
        • extensive atherosclerotic plaque plaque indicating very high cardiovascular disease risk
    • 2022-07-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 29) / 104 = 72.12%
        • M-mode (Teichholz) = 71.8
      • Dilated LA
      • Adequate LV,RV systolic function with normal wall motion
      • Mild LV hypertrophy, Impaired LV relaxation
    • 2022-06-17 Myocardial perfusion SPECT with persantin
      • Probably mild to moderate myocardial ischemia at the inferoseptal wall and mild myocardial ischemia at the apex and anteroseptal wall.
      • Mild reverse redistribution of radioactivity to the inferoapical wall, either normal variant or myocardial ischemia may show this picture.
    • 2022-04-26 Patho - bone marrow biopsy
      • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm, favor chronic myelomonocytic leukemia
      • Microscopically, it shows hypercellularity of bone marrow (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and megakaryocytes.
      • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<=1%), CD71(focal+), CD34(-) and CD117.
    • 2022-10-20 Patho - bone marrow biopsy
      • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm
        • NOTE: The differential diagnosis includes chronic myelomonocytic leukemia and ….. etc.
      • Microscopically, the bone marrow shows hypercellularity (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and a few megakaryocytes.
      • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<5%), CD71(<5%), CD20(-), CD34(-) and CD117(<5%).
  • 2021-07-26 Abdominal Ultrasonography
    • Diagnosis
      • Mild splenomegaly
      • Fatty liver, mild
      • Fatty pancreas
      • Hydropelvis, bilateral
      • Atrophy of right kidney
    • Suggestion
      • Please correlate with clinical information, other imaging and follow sonography in 3-6 mon.
      • Please check LFTs, tumor markers, and metabolic profiles.
  • chemoimmunotherapy
    • 2022-07-08 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-06-10 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-04-25 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-03-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-02-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-01-24 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2021-12-27 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2021-11-30 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7

2023-03-28

[ciclosporin TDM]

Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.

The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.

2022-12-13

The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.

2022-12-13 WBC 670/uL, PLT 2000/uL.

2022-11-28

[cyclosporine trough concentration]

As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.

2022-11-25

[cyclosporine trough concentration]

Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.

According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).

2022-10-20

2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.

701471705

230328

[Diagnosis] - 2023-03-27 admission note

  • High grade serouns carcinoma of bilateral ovaries, pT2bNxMx, at least 2B, s/p Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) the 2023/03/09, ypTxN0(if cM0)
  • Chronic viral hepatitis B without delta-agent

[present illness] - 2023-03-27 admission note

  • This 47-year-old woman patient is a case of Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital). She had palpable progressively enlarging masses over right inguinal area for 4 months. Three months ago, she went to HuaLien TzhChi Hospital GYN OPD due to her progressively enlarging masses over right inguinal area and LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy were done.
  • This time, she came to our GYN OPD on 2023/02/16 seeking second opinion for surgical intervention. Received 3 rd times chemotherapy with Taxol/Carboplatin in Hualien (due to high grade serous carcinoma) on 2023/01/30. Transvaginal sonography on 2023/02/17 revealed multiple myomas 22x18, 23x20, 17x16mm and EM 5.00mm. PES on 2023/03/08 showed chronic superficial gastritis. Colonoscopy on 2023/03/08 showed no immediate complication. Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) on 2023/03/09 and pathology showed AJCC 8th edition pathology stage: ypTxN0(if cM0), high grade serouns carcinoma of bilateral ovaries: pT2b NxMx, at least 2B. Tumor markers on 2023/03/24 showed normal (CA-125:17.8 U/mL, CEA:0.94 ng/mL, CA199- 6.52U/mL). Now, she was admitted to ward for adjuvant chemotherapy with TP (Taxol 175mg/m2, Carboplatin AUC:5)(C4) on 2023/03/28.

[past history] - 2023-03-27 admission note

  • Hypertension without medication control
  • DM:(-) Other
  • medical:denied
  • Not taking any hormone medications
  • Surgical: Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital)
  • Menstrual history: G0P0, Last menstrual period: 2022/11
  • Menarche at the age of 13 years old
  • Menstrual cycle: Duration/Interval: 4-5days/14-28days
  • Amount: moderate without blood clots
  • Last pap smear examination at 2022/9            

[allergy]

  • NKDA

[family history]

  • Father has colon cancer and hypertension.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-09 Patho - uterus with or without SO non-neoplastic/prolapse
    • Ovarian/ Fallopian tube/ Peritoneum Cancer Checklist
    • Diagnosis:
      • Uterus, endometrium, debulking surgery — No residual malignant tumor
      • Uterus, myometrium, debulking surgery — Intramural myoma; adenomatoid tumor; adenomyosis
      • Uterus, cervix, debulking surgery — No residual malignant tumor
      • Omentum, infracolic omentectomy — No residual malignant tumor
      • Lymph node, left iliac, dissection — Negative for malignancy ( 0 / 9)
      • Lymph node, left obturator, dissection — Negative for malignancy ( 0 / 5)
      • Lymph node, right iliac, dissection — Negative for malignancy ( 0 / 5)
      • Lymph node, right obturator, dissection — Negative for malignancy ( 0 / 5)
    • AJCC 8th edition pathology stage: ypTxN0(if cM0)
  • 2023-03-08 Colonoscopy
    • Diagnosis
      • Mixed hemorrhoid, gr 3-4
      • incomplete study due to poor preparation.
    • Suggestion
      • Small lesions may be missed due to inadequate colon preparation.
    • Complication
      • No immediate complication
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2023-02-16 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • Uterine myoma

[surgical operation]

  • 2023-03-09
    • Diagnosis
      • High grade serous carcinoma of bilateral ovaries, pT2bNxMx (2022/12/15), at least IIB, status post glove-port LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15.
    • Surgery:
      • Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection).
    • Finding
      • uterus with multiple small myomas, its total size measuring 7x5cm
      • right side atrophic partial ovary was attached to the posterior wall of the uterus
      • there was dense adhesion from last surgery found between the intestine and left side pelvic wall, adhesionlysis was performed
      • left side pelvic lymph nodes enlarged (+)
      • right side pelvic lymph nodes (-)
      • cytology was performed
      • there was no residual tumor found while entering the pelvic cavity
      • omentectomy was done

[chemotherapy]

  • 2023-03-27 paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • The patient was diagnosed with high grade serous carcinoma of bilateral ovaries, with a pathological stage of pT2bNxMx, at least IIB. She underwent LSO, right ovarian cystectomy, and right salpingectomy on 2022/12/15 and received three cycles of taxol chemotherapy at HuaLien TzhChi Hospital, with the last dose on 2023-01-30. On 2023-03-09, she underwent debulking surgery for ovarian cancer, which included a hysterectomy, right oophorectomy, infracolic omentectomy, and bilateral pelvic lymph node dissection.
  • She was admitted this time for the fourth adjuvant chemotherapy cycle using paclitaxel and carboplatin, with the previous three cycles being administered at HuaLien TzhChi Hospital.
  • Paclitaxel can cause severe hypersensitivity reactions, so the premedication regimen includes dexamethasone, an H1 receptor antagonist (diphenhydramine), and an H2 receptor antagonist (famotidine).
  • Carboplatin is also associated with infusion reactions, which typically occur after six cycles, and no specific premedication regimen is recommended.
  • Lab data on 2023-03-27 showed normal liver and kidney function with CBC grossly in normal range. No dose adjustment is needed for the scheduled chemotherapy.
  • According to the PharmaCloud database, the patient has only taken drugs prescribed at our hospital in the last three months, and there is no medication reconciliation issue.

700335007

230327

[diagnosis] - 2023-03-13 admission note

  • Intrahepatic bile duct carcinoma
  • Type 2 diabetes mellitus without complications
  • Cardiac arrhythmia, unspecified

[past history]

  • Medical PH: recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. NTUH, anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
  • Hospitalization: several times due to UTI
  • urethral stone s/p at NTUH
  • DM (+): under pioglitazone 15mg/metformin 850mg BID, glimepride 2mg QD
  • HTN (-)
  • Peptic ulcer

    

[allergy]

  • NKDA     

[family history]

  • Mother: DM

[exam findings]

  • 2023-03-24, -03-13 KUB
    • S/P clips projecting at the liver
    • Spondylosis of the L-spine is noted.
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 28) / 67 = 58.21%
      • M-mode (Teichholz) = 57
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild to moderate MR, mild AR, moderate TR and trivial PR
        • ChatGPT: In a cardiac echocardiogram, the abbreviations MR, AR, TR, and PR refer to different types of heart valve regurgitation:
          • MR: Mitral regurgitation, which is the backflow of blood from the left ventricle to the left atrium through the mitral valve during systole.
          • AR: Aortic regurgitation, which is the backflow of blood from the aorta to the left ventricle during diastole.
          • TR: Tricuspid regurgitation, which is the backflow of blood from the right ventricle to the right atrium through the tricuspid valve during systole.
          • PR: Pulmonary regurgitation, which is the backflow of blood from the pulmonary artery to the right ventricle during diastole.
      • Preserved RV systolic function
      • Atrial fibrillation with HR 90~128 at the exam
  • 2023-03-14 SONO - abdomen
    • Parenchymal liver disease
    • Post left lobectomy of liver
    • Postcholecystectcomy
  • 2023-03-13 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-03-13 ECG
    • Atrial fibrillation with rapid ventricular response
  • 2023-02-16 CT - abdomen
    • History and indication: intraheapatic cholangiocarcinoma
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P left liver operation without interval change.
      • Hydrops of left scrotum.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • A calcified spot (4.7mm) at RLL.
    • IMP:
      • S/P left liver operation without interval change.
  • 2022-10-24 CT - abdomen
    • Indication
      • First operation for intraheapatic cholangiocarcinoma, cT2N0M0 post Lt lobectomy on 2020/04/15, pT2pNx, well differentiated.
      • NTUH - Anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 NIDDM under OHA for 4 yrs (20220624)
      • History of arrhythmia
    • Abdominal CT with and without enhancement revealed:
      • s/p left hepatic lobectomy.
      • Low density change at caudate lobe about 2.79cm in largest dimension. post op change or others? Suggest closely follow up.
      • Minimal ascites at abdominal cavity is found.
      • Enlarged prostate up to 4.8cm in largest dimension is found.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Non-specific bowel gas at abdominal cavity is found.
      • Visible chest
        • Cardiomegaly is noted.
        • The lung fields are clear.
        • No pleural effusion is found.
      • Suggest clinical correlation
    • Imp: s/p left hepatic lobectomy with low density lesion at caudate lobe about 2.79cm, post op change or recurrent tumor should be D.D. Suggest closely follow up.
  • 2022-06-30 CXR
    • S/P Port-A infusion catheter insertion.
    • Blunted right costophrenic angle.
    • S/P operation with retention of surgical clips.
  • 2022-06-24 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?

MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor >5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites

[consultation]

  • 2023-03-24 Gastroenterology
    • Q
      • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
      • The patient was just discharged last week under the diagnosis of general weakness with mild eleavted liver enzyme suspected poor intake related.
      • The patient sufferred from poor appetite with progressive body weight loss from 54kg -> 50kg in recent one month. Easy satiety with nausea and vomit sensation, he can only tolerate liquid diet intake (the solid food can be swallowed, but the patient vomits immediately after eating.) Mild elevated liver enzyme also noted. KUB during last admission: no ileus, will be followed today. Stool passage only under laxative use recently. Depressive mood also noted and had went to PSY OPD for further managment on 2023/03/22, mertazapine 0.5# HS was precribed. Stool OB obtained in last admission: negative.
      • For poor appeitte with general weakness, we need your expertise for further evaluation and management, thank you!
    • A
      • This time, he was admitted for poor appetite and general weakness. And, we are consulted for problem above.
      • S + O
        • At bedside, stable vital signs noted
        • Recieving blood transfusion
        • Clear conscious,
        • According to his daughter, patient ate well without vomitus yesterday, after stool passage
        • But, vomtius noted today
        • Local tenderness at upper quadrat of abdomen, no rebounding pain
        • normoactive bowel sound
        • Percussion: no tympanic
        • Lab
          • 2023-03-24 Na (Sodium) 133 mmol/L
          • 2023-03-24 K(Potassium) 3.9 mmol/L
          • 2023-03-24 Ca (Calcium) 2.03 mmol/L
          • 2023-03-24 Albumin 2.7 g/dL
          • 2023-03-24 Neutrophil 98.0 %
          • 2023-03-24 S-GPT/ALT 101 U/L
          • 2023-03-24 S-GOT/AST 116 U/L
          • 2023-03-24 Alkaline phosphatase 844 U/L
          • 2023-03-24 Creatinine 0.64 mg/dL
          • 2023-03-24 WBC 14.70 x10^3/uL
          • 2023-03-24 HGB 7.9 g/dL
          • 2023-03-24 PLT 396 x10^3/uL
          • 2023-03-17 HbA1c 8.4 %
      • A: poor appetite, vomitus, suspect gastroparesis, suspected obstruction
      • P:
        • Might be on NG feeding with feeding bag or feeding pump for nutrition support, if still vomitus
        • IVF supplement
        • Give medication with gascon and prokinetic agent such as metoclopramide (IV or PO), mosapride or domperidone
        • Regular follow up KUB (standing KUB) to see if symptoms improved
        • Give medication such as sennoside, dulcolax, lactulose, EVAC to keep stool passage
        • Correct electrolytes imbalance
        • Check thyroid and adrenal function.
        • Correct hypoalbuminemia to improve bowel edema.
        • Arrange upper GI series or EGD to rule out mechanical lesion
        • Arrange abdominal CT (with contrast if no contraindication), if still unknow etiology
        • Consider to use megestrol, if cachexia was suspicious and rule out other cause of poor appetite
  • 2023-03-14 Cardiology
    • Q
      • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
      • Under the impression of unintentional body weight loss with elevated liver enzyme, suspected cancer progression, he was admitted for further survey.
      • Tachycardia with follow up ECG showed Af on admission. According to the patient, he knew he had Af and had ever follow up in CV in the past but lost of follow up for years, anticoagulation was suggested but refused due to personal reasons.
      • We add apixaben 5mg BID for stroke prevention (CHA2DS2 VASC score 2 points)
      • We need your expertise for further evaluation and follow up, thank you!
    • A
      • The patient was examined and hx was reviewed.
      • CHA2DS2 score = 2’ ; HAS-BLED 1’-2’;
      • Suggestion
        • Anticoagulant is indicated for the patient; the risk (eg.: major bleeding rate around 0.1-0.3 %) and indication have been well explained to the patient and his family.
        • Educate about the timing of medication withdrawl.
        • Arrange 2D echo for LV function work-ip.
        • Nebivolol 0.5# qd for rate control.
      • Thanks for your consultation.

[radiotherapy]

  • 2022-07-18 ~ 2022-08-22 - 4500cGy/25 fractions of the recurrent tumor and peripheral area.

[chemotherapy]

  • 2023-02-21 - gemcitabine 1000mg/m2 1544mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-14 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-07 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-31 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-17 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-03 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-20 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-06 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-22 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-08 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-25 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-11 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-27 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-06 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-16 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-02 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-19 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-05 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-03-27

  • The patient was prescribed regular insulin 10 units Q12H at 08:05 on 2023-03-27, while his serum glucose levels have been fluctuating significantly, ranging from less than 100mg/dL to over 200mg/dL (81mg/dL at 06:06 on 2023-03-25 and 109mg/dL at 06:22 on 2023-03-27). It is recommended to closely monitor the patient for signs of hypoglycemia after administering the insulin and adjust the dosage as needed.
  • The patient’s stool occult blood test (OB) is positive (4+, 2023-03-26). Hemoclot (tranexamic acid) 500mg IVD Q12H has been prescribed. The anticoagulant indicated for the patient’s atrial fibrillation is currently withheld due to the patient’s current bleeding.
  • The patient’s constipation has been alleviated with the use of Through (sennoside), lactulose, and EVAC Enema, resulting in 1, 0, 0, and 3 bowel movements on March 23rd to March 26th, respectively.
  • There are no issues with the current prescription.

2023-03-14

  • Elevated liver-related enzymes and hemoglobin breakdown readings above the normal range strongly suggest the possibility of hepatic problems.
    • 2023-03-13 S-GOT/AST 89 U/L
    • 2023-03-13 S-GPT/ALT 113 U/L
    • 2023-03-13 Bilirubin total 1.59 mg/dL
    • 2023-03-13 Bilirubin direct 0.66 mg/dL
    • 2023-03-13 Alkaline phosphatase 688 U/L
    • 2023-03-13 r-GT 876 U/L
  • Despite the administration of insulin and oral antiglycemic agents, the patient has experienced blood sugar levels ranging between 320 to 600 mg/dL during this hospitalization. This marked hyperglycemia can lead to an increase in serum glucose, which in turn raises the serum tonicity. This process draws water out of cells and expands the extracellular water space, resulting in a subsequent lowering of the serum sodium concentration. It is recommended to appropriately increase the insulin dose in order to better manage the patient’s hyperglycemia (and the possibly induced hyponatremia).
    • 2023-03-14 Free-T4 1.18 ng/dL
    • 2023-03-14 TSH 0.890 uIU/mL
    • 2023-03-13 Urine osmolarity 675 mOsm/Kg
    • 2023-03-13 Na (Urine) 46 mmol/L
    • 2023-03-13 K (Urine) 19.9 mmol/L
    • 2023-03-13 Na (Sodium) 127 mmol/L
    • 2023-03-13 Albumin 2.7 g/dL

700537683

230327

[exam findings]

  • 2023-03-23 Ascites tapping
    • 3000mL
  • 2023-03-22, -03-21 CXR
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion.
    • Few gallstones.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-03-21 CT - abdomen
    • History and indication: Pancreatic cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (6.8cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Bil. pleural erffusions with adjacent lung collapse.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity with ascites.
      • Normal appearance of kidneys.
      • Gallbladder stones (up to 1.2cm).
      • Patency of portal vein.
      • Intact bony structures.
      • No obvious extraluminal free air.
      • Minimal pericardial effusion.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion.
      • Cystic lesions (up to 3.1cm) at thyroid glands.
    • IMP:
      • Pancreatic tail with adjacent structures invasion, peritoneal carcinomatosis and liver metastases (progression). Ascites and pleural effusion.
  • 2023-03-20, -03-16 Standing KUB
    • Gallbladder stones.
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-03-14, -02-22 ECG
    • Sinus tachycardia
  • 2022-12-22 CT - chest
    • Indication: pancrease cancer, cT3N1M1, stage IV, for lung metastasis evaluation
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: multiple small randomly distributed pulmonary nodules of varying sizes up to 11mm at RML consistent metastases.
      • Mediastinum and hila: no enlarged LN or mass.
        • small pericardial effusion.
        • mild calcified plaques of the LAD coronary arter.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace effusion.
      • Chest wall and visible lower neck: enlarged thyroid gland with nodular calcifications and cystic lesions up to 42mm.
      • Visible abdominal contents: a large (6cm) at pancreatic tail canceer with adjacent organs invasion, multiple metastatic tumors, regional LNs metastasis, suspect a small tumor in pancreatic head. two gallstones (1.3mm).
    • Impression:
      • advanced pancreatic cancer (stage IV) with lung metastasis.
      • thyroid goiter.
  • 2022-12-21 whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the right aspect of mandible, faint hot spots in both rib cages, and increased activity in the skull, maxilla, a upper T-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • A hot area in the right aspect of mandible and increased activity in a upper T-spine, the nature is to be determined (early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in both rib cages, skull, maxilla, sacrum, bilateral shoulders, S-I joints, hips, and knees.
  • 2022-12-20 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary type, compatible with metastatic pancreatic ductal adenocarcinoma
    • The sections show a picture of pancreatobiliary-type adenocarcinoma, moderately differentiated, composed of nests, and cords of low columnar neoplastic cells with intracytoplasmic and intraluminal mucin, arranged in tubular and cribriform patterns, and embdded in fibrous stroma.
    • IHC shows: CK7(+), CA19-9(+), amd CK20 (focal +).
    • The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
    • Suggest clinic coirrelation.
  • 2022-12-17 CT - abdomen
    • History and indication:
      • liver tumors: suspected metastatic tumors. suspected pancreatic tumor(tail)
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity.
      • Normal appearance of kidneys.
      • Gallbladder stones (up to 1.2cm).
      • Patency of portal vein.
      • Intact bony structures.
      • Small amount ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Some nodules at bilateral basal lungs.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-12-14 SONO - abdomen
    • Diagnosis
      • Hepatic tumors suspected mets
      • Gall stones, two
      • Pancreatic tumor suspected cancer, tail
    • Suggestion
      • abdomen CT
  • 2022-12-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A(minimal)
      • Superficial and atrophic gastritis, antrum, s/p CLO test
      • Gastric polypoid lesion, high body, GC site, suspicious external compression
    • Suggestion
      • Pursue CLO test result
      • Consider arrange CT scan for suspicious external compression
  • 2019-06-03 ENT Hearing Test
    • Tymp: R’t type As; L’t type A
    • ART:
      • R’t ipsi 4k Hz and contra 500 Hz absent
      • L’t ipsi 4k Hz reduced and contra 500 & 4k Hz absent
    • PTA:
      • Reliability fair
      • Average R’t 45 dB HL; L’t 54 dB HL
      • R’t mild to moderately severe SNHL
      • L’t moderate to moderately severe SNHL

[consultation]

  • 2022-12-20 Hemato-Oncology
    • Q
      • This 70 years old female has the history of DM under medication control for years
      • she came to GI OPD for abdomen pain for days and body weight loss 5+ in one month. At OPD abdomen CT was perfromed and reported A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
        • Some LNs at retroperitoneum.
        • Multiple liver tumors.
        • Some soft tissues in peritoneal cavity.
      • Pancreatic Carcinoma T3N1M1 STAGE:IV
      • Bone scan was arranged, we need your further further advise. Thanks
    • A
      • This 70 year old woman is a case of suspect pancreae tail cancer with liver and lung metastasis. She receive CT guide bioipsy for liver tumor on 2022/12/20 morning and pending the result. For pancrease cancer, cT3N1M1, stage IV, we are consulted.
      • Suggestions:
        • Well explain to patient and daughter.
        • May arrange contrast enhance chest CT for lung metastasis during this admission, or arrange in my clinics.
        • Please check AntiHbc, HbsAg, AntiHCV
        • Pending the pathology. We will discuss with patient about further treatment according to pathology result.
        • Please arrange our OPD after being discharged.

[chemotherapy]

  • 2023-03-07 - nab-paclitaxel 100mg/m2 170mg 90min D1,8,15 + gemcitabine 1000mg/m2 1700mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-02-14 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-02-07 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-31 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-17 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-10 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-03 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

700490718

230324

[exam findings]

  • 2023-03-23 CXR
    • Consolidation or mass lesions in left lower lung zone
  • 2023-03-21 Nasopharyngoscopy
    • right OME(+) –> suggest right grommet
  • 2023-03-14 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/10/25.
    • The previously seen mucosal enhancing lesion on the nasopharyngeal posterior wall is less distinct. Favor tumor in regression.
    • Severe paranasal sinusitis.
    • Severe bilateral mastoiditis.
  • 2023-03-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 27) / 113 = 76.11%
      • M-mode (Teichholz) = 76
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, AR
  • 2023-03-07 Nasopharyngoscopy
    • Findings: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
    • Conclusion: NPC
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-02 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-02-23 CXR
    • Atherosclerosis of the aorta.
    • Ground glass opacity in LLL.
  • 2023-02-23 ECG
    • Sinus rhythm with Premature atrial complexes
    • Nonspecific ST and T wave abnormality
  • 2023-02-04 Nasopharyngoscopy
    • Findings: stage cT1N1M0, under CCRT
    • Conclusion: NPscope: left NP tumor regression, NE of tumor noted, crust(+)
  • 2023-01-07 Nasopharyngoscopy
    • Findings: NPC
    • Conclusion: left NP tumor regression, but still residual tumor
  • 2022-11-20 CXR
    • No cardiomegaly
    • No active lung lesion
    • Normal bony contour
  • 2022-11-10 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 33 dB HL
      • L’t : 35 dB HL
      • Bil normal to moderate SNHL.
  • 2022-11-09 CXR
    • Multiple nodules at bil. lungs.
    • Normal appearance of trachea and bil. main bronchus.
    • Normal size of heart.
    • Intact bony structure(s).
  • 2022-11-02 CXR
    • Blunted left costophrenic angle.
    • Normal appearance of trachea and bil. main bronchus.
    • Atherosclerosis of the aorta.
    • Multiple nodules at RUL.
  • 2022-10-25 CXR
    • No cardiomegaly
    • Increased infiltration over right lung and LLL. May be active infection.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-10-26 Tc-99m MDP whole body bone scan
    • IMPRESSION:
      • Increased activity in the skull base and maxilla, either local hyperemia or local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Suspected benign lesions in some T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and left knee.
    • SUGGESTION:
      • Please arrange F-18 FDG PET/CT scan for further staging (Insurance reimbursement indication for head and neck cancer staging).
  • 2022-10-25 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
    • Impression ( Imaging stage ): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-10-18 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, NP biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
    • The specimen submitted consists of a small piece of gray-tan soft tissue, labeled left nasopharynx, measuring 0.5 x 0.3 x 0.2 cm. All for section.
    • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval to spindle-shaped vesicular nuclei and syncytial growth pattern. Keratin formation is absent.
  • 2022-10-18 Nasopharyngoscopy
    • Findings
      • blood tinged NR for one month
      • patient has strong gap reflex, hard to assess NP and larynx by mirror
      • no ABC
    • Diagnosis
      • left NP tumor, suggest NP biopsy
  • 2022-07-27 SONO - abdomen
    • Diagnosis
      • Probable small hemangioma, S6/7
      • Liver cyst, S8
      • Right renal cyst
      • fatty infiltration of pancreas
    • Suggestion
      • OPD follow-up
  • 2022-04-25 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis, s/p CLO test
      • Gastric erosions
      • Cardiac insufficiency
    • Suggestion
      • May give PPI trial
      • Pursue CLO test
  • 2022-01-26 SONO - abdomen
    • Diagnosis
      • Probable small hemangioma, S6/7
      • Liver cyst, S8
      • Right renal cyst
      • Splenomegaly, mild
    • Suggestion
      • OPD follow-up

[consultation]

  • 2023-03-07 Ear Nose Throat
    • Q
      • This 67-year-old man patient is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II s/p concurrent chemoradiotherapy from 2022/12/05 ~ 2022/12/29 and chemotherapy with PF4 (CDDP 80mg/m2, 5FU 1000mg/m2 x4 days) from 2022/11/11. Patient refuse chemotherapy. This time, for F/U. Thank you.
    • A
      • S
        • Hx of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II
        • Suffered from bilateral hearing impairment (tympanocentesis was done before but in vain), dysphagia, sticky sputum, PND, tachycardia after chemo with PF4
      • O
        • Ear drum: bil OME
        • Scope: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
      • Imp:
        • NPC, regression
        • OME, bil, suspect side effects of RT
      • Plan:
        • Treat his symptoms with your expertise
        • ENT OPD f/u for NPC and hearing problem

[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111

  • Treatment Plan: Concurrent chemoradiotherapy (CCRT) + adjuvant chemotherapy.
  • Consensus of the team: cT1N1M0, Stage II.

[chemoimmunotherapy]

  • 2023-02-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-28 - cisplatin 40mg/m2 65mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-21 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-15 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-05 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-11-11 - cisplatin 80mg/m2 135mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (PF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-24

  • Although the patient’s serum sodium levels have never reached the lower limit of normal based on available laboratory data in HIS5 since 2022-10-25, it is worth noting that the patient has been receiving CCRT (CDDP) and PF regimen since 2022-11-11. Cisplatin, a component of the chemotherapy regimen, is known to induce nephrotoxicity, which can manifest as acute kidney injury (AKI) or electrolyte disturbances such as hypomagnesemia and salt-wasting hyponatremia. The patient’s creatinine levels have been observed to be above the normal range more frequently after receiving chemotherapeutic agents. The patient has also experienced hypomagnesemia, which has shown a similar trend despite receiving sodium and magnesium supplements.
    • ref:
      • Cisplatin nephrotoxicity: a review of the literature. J Nephrol. 2018;31(1):15-25. doi:10.1007/s40620-017-0392-z
      • Risk Factors for Severe Hyponatremia Related to Cisplatin: A Retrospective Case-Control Study. Biol Pharm Bull. 2019;42(11):1891-1897. doi:10.1248/bpb.b19-00477
      • Hyponatremia timing, incidence, and associated risk factors in patients treated with cisplatin for lung cancer: a retrospective study. J Popul Ther Clin Pharmacol. 2022;29(4):e1-e10. Published 2022 Oct 7. doi:10.47750/jptcp.2022.907
  • Sodium level correction rate recommendation (ref: Diagnosis and treatment of hyponatremia: compilation of the guidelines. J Am Soc Nephrol 2017; 28(5):1340-1349.)
    • Minimum, 4 to 8 mmol/L/day; MAX 10 to 12 mmol/L/day
    • For patients with high-risk of osmotic demyelination syndrome: Minimum, 4 to 6 mmol/L/day; MAX 8 mmol/L/day

2023-02-09

[mucositis]

As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

701337783

230324

{not completed}

[diagnosis] - 2023-03-22 admission note

  • Adenocarcinoma of middle rectum with lung metastasis, cT4bN0M1a, stage IVA, status post T-colostomy on 2022/11/24 s/p concurrent chemoradiotherapy (radiotherapy to the pelvis and rectal tumor) with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5-FU 2800mg/m2) from 2022/12/06 ongoing
  • Chronic viral hepatitis B without delta-agent
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension

[past history]

Irregular drug use

  • Type 2 diabetes mellitus
    • Onglyza 5mg 1# po QD
    • Loditon(Metformin) 850mg 1# po BID
  • Hypertension
    • Carvedilol 6.25mg 1# po QD
    • Nidil 5mg 1# po BID
    • Funazine 10mg 1# po QD
    • Bestan 300mg 1# po QD
    • Rixia 0.5mg 1# po QD
    • Fylin 400mg 1# po QD
    • Lorazepam 1mg 1# po BID
  • Hyperlipidemia
    • Rosuvastatin 5mg 1# po QD
  • Hyperuricemia
    • Febuton 40mg 1# po QD                    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-20 CT - abdomen
    • Indication: Adenocarcinoma of middle rectum with lung metastasis, cT4aN0M1b, stage IVB
    • Abdominal and Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated soft tissue nodule at left upper lobe measuring 2.6cm in largest dimension is found. (Se401 Im15).
        • Enlarged lymph nodes are found at bilateral paratracheal region.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • s/p colostomy with its orifice at RLQ.
        • Low density lesion at tip of S6 of liver measuring 0.41cm in largest dimension. Simple cyst is favored. Suggest follow up.
        • Eccentric wall thickening at rectum measuring 2.96cm in largest dimension is found. Rectal cancer is favored.
    • Imp:
      • Rectal cancer with suspected left upper lobe lung meta? Mediastinal lymph nodes
  • 2023-02-17 Sigmoidoscopy
    • ircumfererntial rectal cancer s/p CCRT with partial regression (middle rectum, about 7cm AAV). The scope can not be passed through it.
  • 2022-11-23 All-RAS + BRAF mutation
    • Cell Block: S2022-20665
    • RESULTS
      • There was no variant detect in the KRAS/NRAS gene.
      • There was no variant detect in the BRAF gene.
  • 2022-11-23 Whole body PET scan
    • Glucose hypermetabolic lesions at the rectal region, compatible with the primary rectal cancer.
    • Glucose hypermetabolic lesions in the left upper lung, probably a chronic inflammation process, suggesting follow-up.
    • Glucose hypermetabolic lesions in bilateral mediastinal lymph nodes, probably reactive nodes.
    • Glucose hypermetabolic lesions in the right clavicle bone, P/3, gastric region, and left shoulder joint, probably benign in nature.
    • Rectal cancer, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
  • 2022-11-22 Patho - colon biopsy
    • Rectum, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, composed of cords and single columnarto cuboidal neoplastic cells, arranged in focal glandular pattern with desmoplastic stromal reaction. Mucosal ulcer is present.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113- 34) / 113 = 69.91%
      • M-mode (Teichholz) = 69
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild MR, TR and PR
  • 2022-11-21 Flow Volume Loop
    • mild obstructive ventilatory impairment
  • 2021-11-02 Ga-67 Whole body inflammatory scan with SPECT
    • The whole-body gallium inflammation scan with SPECT was performed 24th and 48th hours after injecting 6 mCi of the radiotracer to the patient. The images showed increased radiotracer uptake in a lower C-spine, maxilla, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet. In addition, there was inhomogenously increased tracer uptake in the urethra.
    • IMPRESSION:
      • Increased radiotracer uptake in a lower C-spine, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet, probably polyarthritis.
      • Increased radiotracer uptake in the maxilla, probably dental problems.
      • Increased radiotracer in the urethra, probably UTI, suggesting further investigation.
  • 2021-10-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (117.9- 46.4) / 117.9 = 60.64%
      • M-mode (Teichholz) = 60.6
    • Conclusion:
      • Adequate LV Systolic function with no regional wall motion abnormality at resting state
      • Mild mitral, tricuspid and pulmonic regurgitation
      • Dilated LA and aortic root
  • 2021-10-25 CT - brain
    • IMP: Brain atrophy.
  • 2021-09-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (63.1- 20) / 63.1 = 68.30%
      • M-mode (Teichholz) = 68.3
      • 2D (M-simpson) =70.8
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality (under dopamine infusion)
      • Moderate mitral regurgitation, mild tricuspid regurgitation
      • Dilated LA and aortic root, thick IVS and LVPW

[consultation, not completed]

  • 2022-11-28 Hemato-Oncology
    • Q
      • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. Port-A will be arranged today.
      • RT: CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06.
      • We need your expertise for neoadjuvant CCRT.
    • A
      • Patient examined and Chart reviewed. A case of rectal cancer with suspicious lung and liver mets is noted. I am consulted for the CCRT.
      • My suggestions are:
        • Well discussion with patient and family. (Done)
        • Anti-HBV medication will be prescribed if C/T will be given.
        • For covering the possibility of lung and liver mets, the regimen would be FOLFOX
        • Please arrange the admission to my service if he is discharged.
  • 2022-11-25 Radiation Oncology
    • Q
      • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. We need your expertise for neoadjuvant CCRT.
    • A
      • Neoadjuvant CCRT is indicated.
      • CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06. Thank you very much.

[radiotheray]

  • 2022-12-06 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor: 50.4 Gy/ 28 fx.

[chemotherapy]

  • 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-09 - ditto
  • 2023-02-16 - ditto
  • 2023-01-30 - ditto
  • 2023-01-03 - ditto
  • 2022-12-06 - ditto

[assessment]

  • The patient is tolerating the FOLFOX regimen without any major issues. In addition, based on the TPR panel results, the patient’s blood pressure and blood glucose levels are well-controlled despite having comorbidities of hypertension and diabetes mellitus. Furthermore, there are no identified issues with the active prescription.

700018223

230323

[diagnosis] - 2023-03-22 admission note

  • Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15
  • Gastro-esophageal reflux disease with esophagitis
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Unspecified hemorrhoids

[past history] - 20221213 admission note

  • HTN for 15+ years under medical control
  • History of operation: Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0M1.   

[family history]

  • father: colon cancer was diagnosed at the age of 92, died at the age of 99
  • mother: HTN, aplastic anemia
  • younger brother: HTN
  • elder sister: CVA

[exam findings]

  • 2023-01-31 CT - abdomen
    • S/P left hemicolectomy with focal peritoneal infiltrates, post-op change or recurrence? suggest clinical correlation and follow up study.
    • Focal poor enhancement at right renal parenchyma.
    • Bilateral renal cysts, up to 1.3cm in right kidney.
  • 2022-10-12 Patho - soft tissue tumor, extensive resection
    • Pathologic diagnosis
      • Soft tissue, inguinal area, right, excision — Compatible with angiofibroma of soft tissue
    • Microscopic examination
      • Histologic type: Compatible with angiofibroma of soft tissue, composed of uniform spindle cells in a variable myxoid and collagenous stroma with a nectwork of innumerous small thin-walled, branching blood vessels. Prominent collagenous bundles can be identified focally. Neither necrosis nor marked cellular atypia can be found
      • Mitotic rate: <1/10 high power fields
      • Necrosis: Absent
      • Margins: Free and 0.3 cm from closest margin
      • Lymphvascular invasion: No identified
    • IHC
      • IHC: MUC4(-), SMA(-), Beta-catenin(-), MDM2(-), STAT6(-)
      • Previous IHC (S2022-15033): CD34(-), CD117(-), DOG-1(-), Desmin(-), S100(-), MUC4(-), EMA(-).
  • 2022-09-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Colon, splenic flexure, left hemicolectomy — Mucinous adenocarcinoma, moderately differentiated
      • Resection margins, left hemicolectomy — Radical margin is involved by carcinoma
      • Lymph nodes, mesocolic, left hemicolectomy — Negative for malignancy (0/19)
      • Pathology stage: pT4aN0(cM1a); Stage IVA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Left hemicolectomy
      • Specimen site: Left colon
      • Specimen size: 20.5 cm in length
      • Tumor size: 12.0 x 4.5 cm
      • Tumor location: 3.0 cm and 5.5 cm away from the two resection margins, respectively .
      • Depth of invasion grossly: Pericolic soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A2 = bilateral resection margins, A3 = omentum, A4-A6 = pericolic LNs, A7-A12 = tumor.
    • MICROSCOPIC EXAMINATION
      • Histology: Mucinous adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: To serosa
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Intermediate
      • Margins:
        • Bilateral resection margins: Free
        • Circumferential (radial) margin: Involved by carcinoma
      • Lymph node metastasis, mesocolic: Negative (0/19) (No. Positive / No. Total)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4a (Tumor invades serosa)
        • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
        • Distant Metastasis (pM): cM1a
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: Abscess formation around tumor
      • Tumor regression grading S/P CCRT: N/A
      • IHC: EGFR(+), MLH1(-), PMS2(-), MSH2(+), MSH6(+)
        • Labeled as “right inguinal”, core needle biopsy — spindle cell tumor-like lesion.
        • IHC stains: CD34 (-), CD117 (-), Dog-1 (-): dis-favor gastro-intestinal stromal tumor; desmin (-): dis-favor myomatous origin; S-100 (-): dis-favor nerve origin; Ki-67: <1%. MUC4 (-), EMA (-). No meatstatic adenocarcinoma is present in this specimen.
        • REFERENCE: S2022-15295: colon, splenic flexure: compatible with adenocarcinoma.
  • 2022-09-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 34) / 93 = 63.44%
      • M-mode (Teichholz) = 64
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Trivial MR.
    • Prominent epicardial fat.
  • 2022-09-12 Patho - colon biopsy
    • Colon, splenic flexure, biopsy — Compatible with adenocarcinoma, well differentiated
  • 2022-09-06 CT - abdomen
    • Findings
      • Soft tissue tumor, 11x7.6cm in left upper abdomen with central necrosis, suspected spelnic fluxure malignancy. With left abdominal wall involvement.
      • Large soft tissue tumor, 9.3cm in right inguinal region, suspected metastasis.
      • Right renal cyst, 1.4cm.
      • Unremarkable change of the liver, spleen, pancreas and left kidney.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4a(T_value) N:N1b(N_value) M:M1(M_value) STAGE:____(Stage_value)
    • Impression:
      • Left upper abdomen tumor, r/o splenic flexure colon malignancy. Right inguinal tumor, r/o metastasis. If proven colon malignancy, cstage T4aN1M1. Suggest tissue study.
      • Right renal cyst.

[consultation]

  • 2023-01-14 Dermatology
    • Q
      • This 71-year-old woman patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15.
      • This time, of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome. Now, for F/U and evaluate therapy. Thank you.
    • A
      • This patient suffered from dyskeratotic nails for months.
      • Imp: Tinea unguium
      • Suggestion:
        • Zalain cream * 2 tubes/bid (sertaconazole)
  • 2022-12-13 Plastic and Reconstructive Surgery
    • Q
      • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15. He was admitted for chemotherapy. He underwent excision of the big tumor over right inguinal region on 2022/10/12. Now, for F/U. Thank you.
    • A
      • I will talk to the patient and explain about the temporary post-operative paresthesia. Thanks.
  • 2022-11-29 Dermatology
    • Q
      • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15~. He was admitted for chemotherapy. This time, for bilateral toenails desquamation, suspected athlete’s foot. Thank you.
    • A
      • The patient had sufferred from thickening nail with desqumation change on the toenail with nearby keratosis.
      • Under the impression of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome.
      • The following sugestion:
        • step 1: Exelderm lotion 2 bot QN use. Apply the lotion to the nail crevices (sulconazole)
        • step 2: Sinphraderm cream 1 tube topical QN use over keratotic scales. (urea)

[surgical operation]

  • 2022-10-12
    • Surgery
      • Dx: soft tissue tumor over right inguinal region
      • OP: excision
    • Finding
      • 12cm X 9cm X 9cm, multi-lobulated, smooth surfaced mass located between the sartorius, iliopsoas muscles, inguinal cannal, and the femoral artery
      • a 10F JP was placed over anterior side of upper right thigh for post operative drainage
  • 2022-09-15
    • Surgery
      • Gisgnostic laparoscopy + left hemicolectomy
    • Finding
      • very large tumor with sorrounding adhesion over LUQ.
      • anastomosis by endoGIA*3 + V-lock.
      • Drain into pelvis

[chemoimmunotherapy]

  • 2023-03-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-02 - irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[assessment 2023-01-14, not posted]

  • For tinea unguium, if topical Exelderm (sulconazole, applied since late Nov 2022) and Zalain (sertaconazole, applied since mid Jan 2023) failed to cure it, then oral Fungitech (terbinafine 250mg/tab) 1# QD might be considered as a next line treatment.

[assessment]

  • The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.

  • The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.

  • There were no medication reconciliation issues found in the patient.

  • CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.

700313252

230322

{not completed}

[exam findings]

  • 2023-03-20, -03-06 CXR
    • S/P tracheostomy
    • S/P nasogastric tube insertion
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-03-15 Nasopharyngoscopy
    • hypopharynx lymphoma under R/T
  • 2023-02-17 Whole body PET scan
    • Glucose hypermetabolism in the hypopharynx with downward extension to the proximal portion of the esophagus, compatible wtih lymphoma.
    • Glucose hypermetabolism in a focal area in the dome of the liver and in the left adrenal gland. Lymphoma should be considered.
    • Mild and diffuse glucose hypermetabolism in the bone marrow of the skeleton. Lymphoma involving the bone marrow should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the posterior aspect of bilateral lower lung fields and around the tracheostomy. Inflammatory process is more likely.
  • 2023-02-11 CT - chest
    • Indication: hypopharyngeal lymphoma, suspect recurrent rectal cancer lung metastasis
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Spiculated nodular lesiosn at right upper lobe and left upper lobe. Nature?
        • Soft tissue mass encircling upper esophagus is found measuring 3.8cm in largest dimension.
        • Calcified coronary arteries is found.
        • Mild bilateral pleural effusion is found.
        • Increased pulmonary vasculature is found.
      • Visible abdomen:
        • One low density lesion at dome measuring 3.9cm in largest dimension. Liver meta is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
    • IMP:
      • Nodular lesions at both lungs (n>5). Suggest PET
      • Cervical esophageal tumor. 3.8cm
      • Liver meta.
      • Calcified coronary arteries is found.
  • 2023-02-08 Patho - larynx biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pyriform sinus, right, LMS with laser — Diffuse large B-cell lymphoma, NOS
      • Arytenoid, right, LMS with laser — Diffuse large B-cell lymphoma
      • AE fold, right, LMS with laser — Diffuse large B-cell lymphoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of (1) four small pieces of brownish soft tissue received for frozen section, labeled right pyriform sinus, measuring up to 0.6 x 0.4 x 0.2 cm. All for paraffin section as: F2023-00056FS. (2) multiple small pieces of tan-gray soft tissue, labeled right arytenoid, measuring up to 0.5 x 0.4 x 0.1 cm. All for section as: S2023-02055A. (3) six small pieces of tan-gray soft tissue, labeled right AE fold, measuring up to 0.8 x 0.2 x 0.1 cm. All for section as: S2023-02055B.
    • MICROSCOPIC EXAMINATION
      • The sections of all three specimens show a picture of malignant lymphoma with following features:
      • Specimen: Right pyriform sinus, right arytenoid, and right AE fold
      • Procedure: LMS with laser
      • Tumor site: Right pyriform sinus, right arytenoid, and right AE fold
      • Histologic type: Diffuse large B-cell lymphoma, NOS
      • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(+), BCL6(+), MUM1(+), c-MYC(-) and CD56(-)
  • 2023-02-06 CT - abdomen
    • History and indication: Hypopharyngeal cancer, cT4aN0M0. 20230203 Cr:1.69 liver mass noticed, r/o HCC, r/o metastaisis. DM under metformin
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing tumor (3.5cm) at liver dome.
      • A nodule (6mm) at RML.
      • Left adrenal tumors (1.4cm, 1.6cm).
      • S/P rectal operation.
      • Renal cysts (up to 4.7cm).
      • Normal appearance of spleen, pancreas.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Suspected liver and lung metastases.
  • 2023-02-03 Tc-99m MDP whole body bone scan
    • Increased activity in some C-, T- and L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junction and right foot, compatible with benign joint lesions.
  • 2023-02-03 SONO - abdomen
    • Diagnosis
      • Hepatic tumor, right lobe, nature?
      • Collapse GB
      • Renal cysts, both kidney
      • Poor echo window and poor cooperation.
    • Suggestion
      • 4 phase CT or dynamic MRI study
      • tumor markers
  • 2023-02-01 ENT Hearing Test
    • Tymp:
      • RE type C; LE type Ad.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 80 dB HL; LE >80 dB HL.
      • RE moderately severe to profound MHL.
      • LE moderately severe to profound SNHL.
  • 2023-01-31 CT - neck
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T:4a(T_value) N:0(N_value) M:IVA(M_value) STAGE:____(Stage_value)
  • 2023-01-31 Patho - stomach biopsy
    • Stomach, GC of body, biopsy — erosive gastritis with Helicobacter infection
  • 2023-01-31 Patho - gingival/oral mucosa biopsy
    • Labeled as “right hypopharyx”, biopsy — round blue cell infiltration with marked crush artifact.
    • IHC stains: CK (-), dis-favor carcinoma. CD3 and CD20 stains show a predominant B lymphoid sub-population.
    • The possibility of lymphmoa cannot be excluded. Plaes correlate with clinical and image findings. Further work up, including repeat biopsy, might be considered.
  • 2023-01-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum
    • Suspected gastric erosion, GC of body s/p biopsy
  • 2023-01-30, -01-27 Nasopharyngoscopy
    • rt pyriform sinus tumor, bil movable cords
    • suspected rt HP cancer
  • 2019-11-19 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Bilateral renal cysts
  • 2019-11-11 L spine AP + Lat (indluding sacrum)
    • Osteoporosis and spondylosis of L-spine.
    • Disc collapse at L5-S1.
    • Surgical clips at RUQ.
    • Calcification along abdominal aorta.

[consultation]

  • 2023-03-09 Rehabilitation
    • A
      • P
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2023-02-20 Radiation Oncology
    • A
      • Palliative RT to HPX tumor for 3600cGy/20 fx is suggested for symptom control. CT simulation on 2023/02/20 15:30, and RT will be started on Feb 22 or 23 if feasible.
  • 2023-02-09 Colorectal Surgery
    • Q
      • This 90 year-old man has history of
        • hypertension
        • diabetic mellitus
        • Rectal cancer, stage III, s/p operation twice due to recurrence and oral chemotherapy many years ago
      • This time, he was admitted to our ward for Hypopharyngeal cancer (biopsy: pending) survey. Abdominal echogram and CT revealed liver tumor, favor metastasis, origin unknown. We need your expertise on further examination.
      • The patient has had recurrent rectal cancer for several years but has not been followed up on. CT scans were unable to rule out the presence of a rectal tumor. The patient also has a pharyngeal tumor, and if a colonoscopy is needed, it is not suitable for painless general anesthesia.
  • 2023-02-06 Hemato-Oncology
    • Q
      • This is a 90-year-old man with history of
        • Hypertension
        • Type 2 diabetic mellitus
      • This time, he was admitted to our ward for hypopharyngeal cancer (cT4aN0M0) workup. Concurrent chemoradiotherapy may be arranged after staging. We need your expertise for possible chemotherapy arrangement. Thanks a lot!
    • A
      • This 90 year old man with HTN and DM history is a case of suspect Hypopharyngeal cancer, cT4aN0M0, status post biopsy via LMS on 2023/1/30 (pathology: pending). We are consulted for CCRT.
      • Concurrent cisplatin or cetuximab with radiotherapy may consider in this case. (Due to old age, may prefer bioRT)
        • note: BioRT stands for Biological Radiation Therapy, which is a type of radiation therapy that uses biological agents, such as monoclonal antibodies or immunomodulators, to enhance the effects of radiation treatment. The aim of BioRT is to improve the response of tumor cells to radiation by modifying the tumor microenvironment or by enhancing the immune system’s ability to attack cancer cells.
      • Pending pathology report. Please check HbsAg, Anti Hbc, Anti HCV. 24 hr urine CCR. Arrange port A insertion.
      • Please arrange our OPD after discharge.
  • 2023-02-01 Radiation Oncology
    • A
      • Plan: I will discuss with the patient and his second son on Feb 2, 2pm. RT to HPX and cervical esophagus tumor for 7140cGy/34 fx is suggested for locoregional control if he and his son agree. CT simulation will be arranged after teeth extraction (or teeth extraction is declined).
  • 2023-02-01 Oral and Maxillofacial Surgery
    • Q
      • This is a 90-year-old man with history of
        • Hypertension
        • Type 2 diabetic mellitus
      • This time, he was admitted to our ward for right hypopharyngeal cancer workup. Concurrent chemoradiotherapy may be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
    • A
      • After an oral surgical examination, it is recommended that at least 9 teeth be extracted.
        • If the patient is to continue staying in the hospital, arrangements will be made to begin extracting the teeth during the hospital stay.
        • If the patient is to be discharged, arrangements will be made for outpatient tooth extraction.
        • A family member should be present to accompany the patient during tooth extraction to be aware of the risks involved.
      • If the patient will be discharged first, a NP should prescribe antibiotics to be taken by the patient, and please inform us of the follow-up progress.

[multiteam]

  • 2023-03-12 Social Service
    • Family situation:
      • The patient is a 90-year-old married individual with three sons. The patient, his spouse, and his eldest son live together, and during the hospitalization period, a foreign caregiver was hired to care for the patient in the hospital.
      • The eldest son is unmarried; the second son is married with a son (in college) and a daughter (in junior high school); the third son is married with a son (in junior high school).
    • Assessment and Treatment:
      • The social worker visited the patient in the hospital and had a written conversation with him about his emotional state and sleep condition. The patient wrote that he was suffering due to poor sleep and recent obstructive bowel movements. The social worker promised to communicate with the team and the patient accepted. The patient had no other concerns. The social worker also had a written conversation with the patient about his family situation, to which the patient responded in writing. During the assessment, the patient did not show any suicidal ideation and his low mood was primarily due to illness and poor sleep, but he was cooperating with medical treatment.
      • During the assessment, it was found that the patient’s mood was mainly affected by illness, but he was still able to cooperate with medical treatment. The social worker conveyed to the NP about the patient’s poor sleep and bowel movements, and asked the team to pay attention to this issue.
      • On the same day, the team invited the eldest son to the hospital to listen to the explanation of the patient’s illness and reminded him to prepare for the patient’s discharge. After the explanation, the eldest son accepted the arrangements.

[surgical operation]

  • 2023-02-07
    • Surgery
      • Laryngomicrosurgery with laser for hypopharyngeal tumor excision       
    • Finding
      • bulging tumor over bilateral pyriform sinus

[radiotherapy]

[chemotherapy]

==========

2023-03-22

  • The patient is currently self-carrying Betaloc Zok (metoprolol 100mg) for his hypertension. However, the hospital does not have any metoprolol-containing drugs available in stock.
  • Instead, Urosin (atenolol 100mg/tab) is available, which selectively blocks beta 1 receptors and has little to no effect on beta 2 receptors except at high doses.
  • Atenolol 75mg is approximately equivalent to metoprolol 150mg (ref: https://www.whocc.no/atc_ddd_index/?code=C07AB). Therefore, if the intended dose of Betaloc is 1 tablet per day, we recommend taking half a tablet of Urosin per day (0.5# QD).

2023-03-13

  • PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.

    • 2023-03-13 Na (Sodium) 128 mmol/L
    • 2023-03-06 Na (Sodium) 128 mmol/L
    • 2023-03-01 Na (Sodium) 128 mmol/L
    • 2023-02-27 Na (Sodium) 130 mmol/L
    • 2023-02-20 Na (Sodium) 132 mmol/L
    • 2023-02-16 Na (Sodium) 130 mmol/L
    • 2023-01-30 Na (Sodium) 136 mmol/L
  • Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.

  • Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.

  • It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.

700887556

230322

[exam findings]

  • 2023-03-20 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot/faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T- and L-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • No previous study for comparison.
      • Some hot/faint hot spots in both rib cages, and increased activity in the sternum and some T- and L-spine, cancer with bone metastases may be considered, suggesting further evaluation and follow-up with bone scna in 3 months.
      • Suspected benign lesions in the maxilla, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-03-18 CXR
    • Increased infiltration over RLL. May be active infection.
  • 2023-03-16 CXR
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 Patho - stomach biopsy
    • Nodularity of mucosa, LC side of upper body, biopsy — Compatible with fundic gland polyp
    • Microscopically, the sections show a picture of benign gastric mucosa with parietal and chief cells, compatible with fundic gland polyp.
  • 2023-03-15 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated
    • The sections show a picture of poorly differentiated adenocarcinoma, composed of solid nests and cords of polygonal neoplastic cells in fibrous stroma. Vascular invasion and subtle glandular differentiation are present.
    • IHC shows following features: CK7(+), CK20(-), p40(-), TTF1(-), and CDX2(-). Metastatic carcinoma from either lung or colon is less likely. Suggest clinic correlation.
  • 2023-03-10 CT - chest
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest abd Abdominal CT with and without enhancement revealed:
      • Chest:
        • Tiny nodule at right middle lobe measuring 0.3cm is found. Suggest follow up.
        • Senile fibrotic change is noted at lung fields.
        • Patent airway is found.
        • Non-specific lymph nodes are found in the mediastinum.
        • Bilateral mild pleural effusion is found.
        • Calcified coronary arteries is found.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • Left renal atrophy is found.
        • The spleen, liver, pancreas and adrenals are intact.
        • Diffuse liver meta up to 6.8cm at S4 is found.
        • There is no evidence of destructive bone lesion.
        • The GB is well distended without soft tissue lesion
        • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Imp:
      • Diffuse liver meta.
        • The primary tumor cannot be estimated in the study.
        • Please correlate with tumor marker and suggest panendoscopy.
      • Bone meta at thoracic spine.
  • 2023-03-08 MRI - T-spine
    • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
    • With and Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
      • normal bone alignment of the spine
      • unremarkable change in the perivertebral regions
      • unremarkable change in the visible cord.
      • unremarkable change in the disc spaces
      • multiple heterogeneous enhancing lesions in the S1, L5, L4, L3, L2, T11, T10, T5 and T3 vertebral bodies with pathological compression fracture at L4 vertebral body
    • IMP:
      • multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Left anterior fascicular block
    • Bifascicular block
  • 2023-03-07 L-spine flex. + ext. (including sacrum)
    • Marked degenerative change of the spine with marginal spur formation. Disc space narrowing at multiple levels. Geographic bone lesions at L2, L3, L4 levels. Suggest further evaluation.
  • 2023-03-06 MRI - L-spine
    • Indication: Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT. The pain became worse in recent days that he needed bed rest. unable to walk.
    • Imaging protocol: 3-4mm slice thickness; sagittal T1, T2 & STIR, axial T1 & T2, and coronal STIR images
    • MRI of lumbar spine without Gadolinium-based contrast enhancement shows:
      • straightening alignment of lumbar spine.
      • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • multiple geographic bone lesions of abnormal signal change at anterior T11, L2, L3, L4, L5 vertebral bodies, bilateral L4 pedicles and posterior elements, sacrum (S1) and right iliac bone, suspect bone metastases. Suggest further evluation.
      • L4 compression fracture with curvilinear fracture line, favor pathological compression fracture.
      • severe right L4-5, L5-S1 neuroforaminal narrowing.
      • severe L2-3, L3-4, L4-5 central canal stenosis.
      • no evidence of abnormal signal lesion in visible spinal cord.
      • multiple left renal cysts; left hydronephrosis.
    • Impression:
      • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
      • L4 compression fracture, favor pathological fracture.
      • Degenerative spinal and disc disease.
      • Severe right L4-5, L5-S1 neuroforaminal narrowing.
      • Severe L2-3, L3-4, L4-5 central canal stenosis.
  • 2023-03-05 CT - pelvis - bone
    • History and indication: back pain
    • IMP:
      • Atrophy of left kidney. Bil. renal cysts (up to 2.1cm).
      • Compression fracture of L4.
  • 2023-03-04 L-spine AP + Lat (including sacrum)
    • AP and lateral films of the lumbar spine shows:
      • Compression fracture of T12.
      • Degeneration and spondylosis of L-S spine.

[consultation]

  • 2023-03-13 Ear Nose Throat
    • Q
      • This 68-year-old man patient suffered back psin in 2023/01. Progression back pain in 2023/02.
      • Pelvic CT on 2023/03/04 showed atrophy of left kidney, bilateral renal cysts (up to 2.1cm) and compression fracture of L4.
      • L-spine MRI on 2023/03/06 showed
        • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
        • L4 compression fracture, favor pathological fracture.
        • Degenerative spinal and disc disease.
        • Severe right L4-5, L5-S1 neuroforaminal narrowing.
        • Severe L2-3, L3-4, L4-5 central canal stenosis.
      • T-spine MRI on 2023/03/08 showed multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
      • Tumor mark with SCC on 2023/03/09 showed increased (SCC:2.0ng/mL).
      • Chest CT on 2023/03/10 showed diffuse liver meta. The primary tumor cannot be estimated in the study and bone meta at thoracic spine.
      • Now, for evaluate R/O head and neck cancer with liver and bone metastases for SCC increased. Thank you.
    • A
      • Local finding:
        • Oral cavity: fibrosis over bilateral buccal mucosa.
        • Oropharynx: fibrotic change over bilateral tonsillar fossa.
        • Neck: no palpable neck mass.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord.
      • Impression: No definitive finding of ENT lesion indicating malignancy in this visit.
  • 2023-03-09 Dermatology
    • Q
      • This time, for bilateral lower limbs skin edema with dull dandruff and pain in 2017.
      • Now, for evaluate bilateral lower limbs, R/O jock itch therapy. Thank you.
    • A
      • The patient had sufferred from dry swelling legs with fissiform scales and stasis change.
      • Under the impression of stasis dermatitis with ichthyosis change.
      • The following sugeetion:
        • wound protection:
          • Biomycin onit 1 tube topical bid use for wound care first.
          • Sinphraderm cream 1 tube topical QN use over dry scales for mositurization.
        • notice further circulation state, avoid peripheral swelling edema state.
  • 2023-03-07 Neurosurgery
    • Q
      • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
      • The pain became worse in recent days that he needed bed rest
      • unable to walk
      • Past Hx of HTN, DM, lower limbs lymphedema
      • stilck used for Lt knee degeneration
      • 2022/12/17 Cre 1.18 mg/dL
    • A
      • 68 y/o male.
      • Low back and right hip pain for more than 1 month. The pain became worse in recent days so that he needed bed rest and was unable to walk.
      • L-spine MRI:
        • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone.
        • L4 compression fracture, favor pathological fracture.
        • Degenerative spinal and disc disease.
        • Severe right L4-5, L5-S1 neuroforaminal narrowing.
        • Severe L2-3, L3-4, L4-5 central canal stenosis.
      • Advice:
        • Enhanced L-spine MRI (and T- and C-spine).

==========

2023-03-22

  • On 2023-03-19, the urinalysis results showed bacteriuria, UTI, occult blood, and leukocyte esterase positivity. Additionally, there was a significant increase in serum creatinine and a decrease in eGFR.
    • 2023-03-18 Creatinine 3.32 mg/dL
    • 2023-03-16 Creatinine 1.61 mg/dL
    • 2023-03-13 Creatinine 1.20 mg/dL
    • 2023-03-09 Creatinine 1.14 mg/dL
    • 2023-03-18 eGFR 19.78
    • 2023-03-16 eGFR 45.59
    • 2023-03-13 eGFR 63.99
    • 2023-03-09 eGFR 67.90
  • Please ensure that the patient is receiving enough fluids to maintain adequate hydration, and that his fluid input and output are being closely monitored? Additionally, it is important to closely monitor for any signs of infection and track the patient’s renal function.

2023-03-20

  • Bone mets were found, but the primary original malignancy has not yet been identified. Investigation is ongoing.
  • The patient’s son said on the phone that the patient had no contact with any family members after the divorce with his mother, so no family members would care, and said he would discuss with other family members whether to come to the hospital to understand his condition.
  • 2023-03-18 Cre 3.32mg/dL, eGFR 19.78, no height or weight data currently available, CrCl cannot be calculated. If eGFR is considered CrCl and the planned levofloxacin dose is 750 mg QD, in case of CrCl < 20 mL/min: 750 mg initial dose, then 500 mg QOD is recommended.

701474112

230322

[exam findings]

  • 2023-03-17 Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Sample Number: S2023-4736
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-15 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 Patho - lung transbronchial biopsy
    • Lung, LLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2023-03-14 Bone Scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the middle T-spines and increased activity in the skull, lower T-spines, some L-spines, left S-I joint and inferior aspect of left acetabulum in whole body survey.
    • IMPRESSION:
      • Two hot spots in the middle T-spines and increased activity in the skull. Multiple bone metastases may show this picture.
      • Increased activity in the left S-I joint and inferior aspect of left acetabulum. Bone metastases can not be ruled out.
      • Increased activity in lower T-spines and some L-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
  • 2023-03-13 Bronchoscopy
    • normal
    • no obvious tumor was found
  • 2023-03-09 CT - chest
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at left lower lobe measuring 2.7cm is found. Lung cancer is considered. The lession attached to descending aorta and pulmonary artery.
        • Interfissural nodules (n > 10) are found at left upper and lower lobes up to 1.07cm in largest dimension.
        • Mild left pleural effusion is found.
        • Enlarged lymph nodes are found at left hilar and left paratracheal region.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • Imp: left lower lobe lung cancer with lung to ipsilateral lung meta, pleural meta.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-03-09 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Finding: The repetitive stimulation study shows borderline decremental response in Trapezius.
    • Conclusion: The findings are possibly suggestive of myasthenia gravis. Please correlate clinically
  • 2023-03-06 MRA - brain
    • Indication: CT showed brain and skull lesion
    • Imaging protocol: 4-5mm slice thickness; sagittal T2, axial T2 & T2 FLAIR, DWI(b=1000)/ADC, coronal T1, axial T1+C, coronal T1+C images, and TOF MRA images
    • Head MRI without/with Gadolinium-based contrast enhancement shows:
      • multiple heterogeneous enhancing brain tumors scattered in bilateral cerebra and cerebella, on the cortex and in subcortical white matter, some associated with vasogenic edema. Larger ones are 1.8cm at left medial temporal lobe, and 2.0cm at right parietal-occipital lobe junction. Brain metastases are favored.
      • multiple enhancing bone tumors involving skull base and calvarial vault, larger ones are 3.9cm at right high parietal skull, and 2.0cm at clivus. Multiple bone metastases are favored.
      • symmetric size of bilateral ventricles.
      • no brain herniation.
      • TOF MRA shows patent and unremarkable intracranial arteries.
    • Impression:
      • Multiple brain and cerebellar metastases.
      • Multiple bone metastases, skull base and calvarial vault.
  • 2023-03-06 CXR
    • Blunting of left CP angle
  • 2023-03-06 CT - brain
    • Indication: SBP200-220mmHg or DBP110-130mmHg
      • noted today with blurred vision ; no recent head injury
      • no vomiting; no fever ; chest discomfort also noted
    • Imaging Protocol: 4mm slice thickness, axial scan and sagittal reconstruction
    • Without-contrast CT of brain shows:
      • White matter edema in right parietal lobe. Suspicious lesion in left medial temporal lobe.
      • Multiple mass lesions in skull, as well as in clivus.
      • Normal size of the ventricles.
      • No midline shift.
    • Impression
      • White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, suspected brain metastasis
      • Multiple skull lesions; DDx: metastasis, multiple myeloma

[consultation]

  • 2023-03-17 Radiation Oncology
    • A
      • A: Adenocarcinoma of the lung, LLL, stage cT4N2M1, with multiple bone and brain metastases.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastases
        • Goal: palliation
        • Treatment target and volume: the metastatic brain tumors and involved skull bone
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions of the metastatic brain tumors and involved skull bone
        • The treatment planning of radiotherapy will be started at 0930, 2023-3-20.
  • 2023-03-08 Neurology
    • Q
      • She presented with sudden blurred vision and diplopia from 2023/03/06 morning after waking up. Dizziness and occasionally headache was also noted. Occasionally headache and progression memory deterioration for years.
    • A
      • Under the impression of multiple brain and cerebellar metastases with unknow primary, the patient was recommanded admission for further examination and treatment. I was consulted for further evaluation.
      • O
        • NE E4V5M6
        • CNs: suspect left gaze diplopia, no EOM abnormality
        • MP full
        • sensation: intact
        • FNF: no dysmetria
        • gait: steady
        • Brain CT revealed: 1. White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, r/o brain metastasis 2. Multiple skull lesions; DDx: metastasis, multiple myeloma
        • Brain MRI/MRA: 1. Multiple brain and cerebellar metastases. 2. Multiple bone metastases, skull base and calvarial vault.
      • impression:
        • suspect diplopia, r/o leptomeningeal carcinomatosis, r/o cranial neuropathy
      • suggestion:
        • treat cancer as your expertise and agree with steroid treatment
        • consider CSF study to rule out cranial neuritis or leptomeningeal carcinomatosis
        • check serum ACHR ab and RST to rule out myasthenia gravis/LES
        • contact me if any questions and thank you for consultation.
  • 2023-03-08 Dermatology
    • Q
      • She presented skin itchy at least 10 years, SLE (skin manifestations) was diagnosis in RenAi Hospital, follow up and medication for 3 years. She had lesions of skin on her head, right calf and buttocks. Due to brain metastasis was found, skin malignancy was suspicious. We need your further evaluation and management. Maybe need to biopsy?
      • She receive cryotherapy for skin lesions at LMD (2023/03/03).
    • A
      • The patient had sufferred from several itchy keraotsis over face, forarm and buttock s/p cryotherapy with poor healing state.
      • Under the impression of irriated seborrheic keratosis with partial destruction.
      • The following sugeetion:
        • Tetracycline onit. 1 tube topical bid use over wound and crust and Betason-N onit 2 tube topical bid use over regional erythematous itchy lesion
        • If some remain itchy keraotsis develop, avoid self-scretch and consider add Rinderon-V cream 1 tube topical bid use.
  • 2023-03-07 Neurosurgery
    • Q
      • MRA: Multiple brain and cerebellar metastases
      • Dizziness and blurred vision
    • A
      • 67 y/o female. Comorbid with SLE.
      • Brain MRI:
        • Multiple brain and cerebellar metastases.
        • Multiple bone metastases, skull base and calvarial vault.
      • Rx:
        • Consult with oncologist for systemic work-up and therapy.

2023-03-08

[assessment]

  • This 67-year-old female with comorbid SLE presented with dizziness and blurred vision. Brain MRI showed multiple brain and cerebellar metastases, as well as multiple bone metastases in the skull base and calvarial vault. The patient is currently receiving care from our oncologist for systemic evaluation and treatment.
  • The medications previously prescribed by Taipei City Hospital for the patient’s systemic connective tissue involvement have been properly added to the active medication list without a reconciliation issue.

700045553

230321

{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}

[diagnosis] - 2023-03-20 admission note

  • Sigmoid cancer with Metastasis in S7 liver S/P C/T shows progressive disease. Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease. stage IV
  • Viral hepatitis B Anti-HBc positive
  • Type 2 diabetes mellitus without complications

[past history] - 2022-11-25 admission note

  • Type 2 DM
  • Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018.
  • Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 20191226
  • Pig-tail drainage for liver abscess since 2019/06/08.
  • Enterocutaneous fistula since 2019/08/03

[family history]

  • His mother had cervical cancer.

[lab data]

  • 2021-07-30 Anti-HCV Nonreactive
  • 2021-07-30 Anti-HCV Value 0.05 S/CO
  • 2021-07-30 HBsAg Nonreactive
  • 2021-07-30 HBsAg (Value) 0.41 S/CO
  • 2021-07-30 Anti-HBc Reactive
  • 2021-07-30 Anti-HBc-Value 6.63 S/CO
  • 2021-07-30 Anti-HBs 22.86 mIU/mL

[exam findings]

  • 2023-01-27 MRI - T-spine
    • Indication: Mid-back pain and soreness, associated numbness.
    • Findings
      • T1-hypointensity, heterogeneous T2-hypointensity and inhomogeneous enhancement involving both anterior and posterior components of C6, C7, T3, T4 and T5 vertebral body, indicating metastases. Much more severe at T3-5 levels with bony destruction and compression on spinal cord.
      • An enhacning soft tissue mass, about 39 mm at the largest dimension, with irregular maring in right lung field, abutting right main bronchus and right side of T5 vertebrla body, indicating metastasis.
      • No intramedullary lesion.
    • IMP: Bony metastases (C6-7 and T3-5 vertebral bodies) and right lung metastasis.
  • 2023-01-16 CT - Sella
    • Findings
      • An extra-axial tumor (36 mm) at anterior cranial fossa base, can be separated from pituitary fossa by diaphragm sella. Suspected meningioma.
      • After IV contrast administration shows well and homogenous enhancement of the mass or tumor.
    • IMP: Favor a middle frontal base meningioma.
  • 2023-01-16 T-spine AP + Lat.
    • Destructions/metastases, at least, at T3-4-5.
  • 2022-12-13 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, colonic origin
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present. Extensive tumor necrosis is evident.
    • IHC shows: CK7(-), CK20(+) and CDX2(+). The finding is consistent with metastatic colonic adenocarcinoma.
  • 2022-11-28 CT - abdomen
    • Findings
      • Lobulated hepatic tumor at S7/8 of liver up to 5.5cm in largest dimension is found. In comparison with CT dated on 2022-08-10, the lesion enlarged.
      • Diffuse confluent lymphadenopathy at para-aortic and mesenterric region is found. In progression.
      • Mild bilateral pleural effuison is found.
    • Imp:
      • Hepatic meta. In progression.
      • Extensive lymphadenopathy in the abodminal cavity, in enlargement.
  • 2022-09-15 Tc-99m MDP whole body bone scan
    • Prominently increased activity in some upper T-spines. Bone metastases should be considered first.
    • Mildly increased activity in bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, compatible with benign joint lesions.
  • 2022-08-27 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-08-10 CT - abdomen
    • Indication
      • History: D-colon cancer with liver & LNs mets
        • 20180406 CT: Distal D-colon cancer — acute total obstruction
        • 20190520 CT: metastasis in S4/8
        • 20190608 CT: metastasis in S4/8 S/P resection with abscess S/P catheter drainage
        • 20201014 CT: metastasis in S7 S/P C/T with partial response.
        • 20211109 CT: metastasis in S7 1.6 cm.
    • Findings
      • Prior CT identified an ill-defined rim enhancing lesion 4.4 cm in S7 of the liver is noted again, increasing in size to 5.3 cm in the current CT that is c/w liver metastasis S/P C/T with progressive disease.
      • Prior CT identified multiple confluent metastatic lymphadenopathy at para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P C/T with stable disease.
      • S/P surgical resection of S4/8 junction and partial resection of S5/6 of the liver. S/P cholecystectomy. Mild Fatty liver is noted.
      • S/P left hemicolectomy.
      • The spleen shows prominence in size (AP dimension: 11.3 cm).
    • Impression:
      • Metastasis in S7 liver S/P C/T shows progressive disease.
      • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease.
  • 2022-08-04 CXR
    • Cardiomegaly is noted.
    • Right pleural effusion is found.
  • 2022-07-21 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-05-26 CT - abdomen, pelvis
    • Progression of liver/ LNs metastases.
  • 2022-03-12 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-01-15 MRI - nasopharynx
    • Metastastic LAPs at left neck. An extra-axial tumor (37 mm) at anterior cranial fossa and pituitary fossa.
    • Suspected meningioma.
    • D/D: craniopharyngioma, pituitary adenoma, metastasis.
  • 2022-01-14 CT - whole abdomen, pelvis
    • Metastasis in S7 liver S/P C/T shows progressive disease.
    • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show partial response.
  • 2021-11-10 MRI - nasopharynx
    • multiple enlarged and necrotic lymph nodes in the left lower neck and left supraclavicular fossa.
  • 2021-11-09 CT - whole abdomen, pelvis
    • Hepatic meta at S7, in progression.
    • Extensive paraaortic lymphadenopathy, enlarged.
    • Tiny left upper lobe nodule. Stable.
  • 2021-09-16 CT - whole abdomen, pelvis
    • Progression of liver/LNs metastases.
  • 2021-07-19 Patho - peritoneum biopsy
    • newly developed retroperitoneal LNs, R/I recurrence.
    • malignant neoplasm of descending colon
    • Retroperitoneal lymph node, CT-guide biopsy - Adenocarcinoma, metastatic
    • IHC: CK(+), CK20(-), CDX2(+) and CD31 highlights endothelial cell, compatible with metastatic colonic adenocarcinoma.
  • 2020-10-14 CT - whole abdomen, pelvis
    • A metastasis 2.9 x 2 cm in S7 of the liver S/P C/T with partial response. Follow up is indicated.
  • 2020-08-25 CT - whole abdomen, pelvis
    • Post-op at the liver with loculated fluid in right subphrenic region, stationary.
    • Stationary of S7 liver tumor.
  • 2020-06-15 MRI - brain
    • A pituitary macroadenoma. No evidence of brain metastasis.
  • 2020-06-13 CT - whole abdomen, pelvis
    • Post-op at the liver with loculated fluid in right subphrenic region with progression. Post-op biloma or associated with recurrenct, suggest tissue study.
    • Stationary of S7 liver tumor.
    • Small bilateral renal stones.
  • 2020-04-01 CT
    • A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.

    • 2019-11-21 Whole body PET scan

      • Three glucose hypermetabolic lesions in the segment 8 of liver, in the segment 7 of liver and in the right upper abdomen just in the inferomedial aspect of the right lobe of liver respectively. Metastatic lesions should be considered.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and in the soft tissues around bilateral hips. Inflammatory process is more likely.
      • Glucose hypermetabolism in the midline anterior abdominal wall. The nature is to be determined (post-operative change? other nature?).
      • A glucose hypermetabolic lesion the pituitary fossa. The nature is to be determined (some kind of pituitary tumor? other nature?).
    • 2019-11-11 CT - abdomen

      • S/P liver operation. A low attenuation lesion (1.8cm) in S7 of liver without interval change.
    • 2019-08-14 Tc-99m MDP whole body bone scan

      • A faint hot spot in the anterolateral aspect of the right 8th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scna in 3 months for further evaluation.
      • Suspected benign lesions in the left zygomatic bone, inferior angle of the right scapula, bilateral shoulders, and S-I joints.
    • 2019-08-03 MRI - liver, spleen

      • s/p pigtail placement at previous op. region. Some fluid accumulation at previous op. region with tiny air bubble is found. The adjacent liver parenchyma is hyperemic, suspected regional residual abscess formation.
    • 2019-06-06 Surgical pathology Level V

      • pathologic diagnosis
        • Liver, S4-5-8, segmental hepatectomy — Metastatic colonic adenocarcinoma
        • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
        • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
        • Lymph nodes, group 12, lymphadenectomy — Negative (0/3)
      • microscopic examination
        • Diagnosis: Metastatic colonic adenoarcinoma x2
        • Histologic grade: Moderately differentiated
        • Tumor growth pattern: Pushing
        • Tumor pseudocapsule: Present
        • Tumor necrosis: Marked (60%)
        • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.1 cm (S4-5-8) and 0.1 cm (S7), respectively
        • Vascular invasion: Present
        • Perineural invasion: Not identified
        • Tumor regression grade: Grade 4/5 (residual cancer cells predominate over fibrosis)
        • Lymph nodes, group 12: Negative (0/3) (LN involved/LN examined)
        • Non-neoplastic liver parenchyma: Perivenular congestion, and mild portal lymphocytic infiltration
        • Fatty Change: Moderate (50%)
    • 2019-06-08 CT - abdomen

      • S/P operation. Bil. pleural effusion with adjacent lung collapse.
      • Some air and fluid collection in upper peritoneal cavity and right subphrenic region.
      • Inhomogeneous enhancement of right hepatic lobe.
    • 2019-05-20 CT - abdomen

      • Metastasis 4 cm in size at S4 of the liver is noted and it shows indentation or invasion of the gallbladder wall.
    • 2018-11-16 CT

      • S/P left hemicolectomy. Suggest follow up.
    • 2018-07-07 CT

      • S/P operation. Presence of incisional hernia. Focal fat stranding of abdominal wound.
    • 2018-06-28 Surgical pathology Level III

      • Soft tissue, site?, debridement — Ulcer with granulation tissue
    • 2018-04-26 Surgical pathology Level VI

      • Pathologic diagnosis
        • Descending colon, left hemicolectomy — Adenocarcinoma, moderately differentiated
        • Resection margins: Free
        • Lymph nodes, mesocolic, dissection — Metastatic adenocarcinoma (2/16)
        • Pathology stage: pT4aN1b(cMx); Stage IIIB at least
      • Microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Mesocolic soft tissue
        • Angiolymphatic invasion: Present
        • Perineural invasion: Present
        • Discontinuous extramural tumor extension: Not identified
        • Serosal margin status of colon: Involved
        • Lymph nodes metastasis, mesocolic: Metastatic adenocarcinoma (2/16) (No. Positive / No. Total)
        • Extranodal involvement: Present
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)

[consultation]

  • 2023-02-03 Radiation Oncology
    • A
      • In the past 2 wks, he sufferred from Lt neck enlarging LAPs compression with severe Lt arm and scapular pain. CT-simulation will be arranged on 20230208.
      • Plan to deliver 20 Gy/ 4 fx to the Lt neck LAPs. The dose schedule to the spine mets will be adjusted according to the dose distribution and constraint by then.
      • RT will start around 20230209.
  • 2022-12-14 Radiation Oncology
    • A
      • Paraaortic enlarging LAPs have caused mild lower limbs edema already. Palliative RT is indicated. CT-simulation will be arranged on 20231219.
      • Plan to deliver 40~45 Gy/ 20~25 fx to the paraaortic LAPs. RT will start around 2022/12/21 or 22.
    • 2022-12-12 Radiation Oncology
      • Q
        • for CT guide biopsy of liver
        • This 60-year-old man, a patient of colon cancer with liver mets progression and he was admitted for C/T. The abdominal CT showed hepatic tumor progression. We need expertise to evaluate his condition thanks!
      • A
        • According to the clinical history and imaging findings, biopsy is indicated.
    • 2022-09-27 Radiation Oncology
      • A
        • Mr. Hsu, a 60-year-old man with history of Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018. Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 2019/12/26. status during palliative C/T with liver metastases and abdominal LAPs progression.
        • The Lt upper back and shoulder pain and soreness has been noted since one month ago. Bone scan on 20220916 revealed prominently increased activity in some upper T-spines. Bone metastases should be considered first.
        • Palliative RT to the upper T-spine metastases is indicated. CT-simulation will be arranged today. Plan to deliver 30 Gy/ 10 fx to the site mentioned above. RT will start around 20220928 or 20220929. Thank you very much.
    • 2022-08-11 Colorectal Surgery
      • Q
        • for suspected fistular
        • This 60-year-old man, a patient of colon cancer with liver mets progression and Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease S/P C/T. He was admitted due to dyspnea & bak pain on 8/4 22 night abdominal wound poor healing & pus discharge for one week. pus discharge and stool passage via poor healing wound was noted suspected fistular related. We need expertise to evaluate his condition thanks!
      • A
        • The patient was case of colon cancer with liver and LN metastasis
        • Colo-cutaneous fistula was noted
        • PE: Abd: soft; no peritoneal sign; no abdominal pain
        • Imp: Colon cancer s/p op with enterocutaneous fistula
        • Suggestion:
          • Cover with colostomy bag and may contact stoma nurse if needed
          • Keep on palliative chemotherapy
    • 2022-03-15 Ophthalmology
      • Q
        • For left eye reddish for days
        • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted for chemotherapy. He compalined of left eye reddish for days. We need expertise to evaluate his condition. thanks!
      • A
        • S
          • For redness, FBS os for 1 week
          • OPHx: trichiasis s/p epilation od 2wk ago
          • PHx: DM, colon cancer with liver & lung mets progression under Erbitux, FOLFIRINOX
          • NKA
        • O
          • BCVA: OD 0.6(0.9X-0.25/-0.50X40) OS 0.3(0.5X0/-0.50X5)
          • PT: 20/18mmHg
          • Pupil: 3mm, light reflex +, no RAPD
          • Eyelash: entropion with trichiasis os
          • Conj: np od, inferior injected os
          • K: clear ou, inferior spks os
          • A/C: deep/clear ou
          • Lens: ns+ ou
          • Fundus: c/d 0.4, one CWS near disc od, one blot hemorrhage and CWS os
        • A:
          • Entropion with corneal abrasion os
          • Mild diabetic retinopathy ou
        • P:
          • Control blood sugar
          • Sinomin 1gtt QID os + Tetracycline oint HS os + tapping inferior eyelid os
          • OPH OPD f/u for entropion and f/u cotton-wool spot at disc os

[surgical operation]

  • 2019-06-05
    • Segmental hepatectomy
    • Secondary liver malignant neoplasm
  • 2018-06-27
    • Colon cancer s/p op with enterocutaneous fistula
  • 2018-06-22
    • Malignant colon neoplasm, desc
    • 8.5 Fr. B. braun port, left cephalic vein, cut-down method.
  • 2018-05-01
    • D-colon cancer obstruction post op
    • Smoe necrotic tissue at colostomy opened wound
    • Debridement and closure and set a penrose drain
  • 2018-04-25
    • D-colon cancer obstruction s/p colostomy
    • D-colon cancer with complete obstruction 744cm
    • Peristoma dense adhesion with omentum and small intestine
  • 2018-04-10
    • D-colon cancer obstruction
    • Severe dilatation of T-colon and short mesentary
    • Asites (+)

[chemotherapy]

  • 2023-03-20 - irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5290mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-01 - cetuximab 250mg/m2 100mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5280mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-06 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-01-04 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-12-14 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

    • 2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)

      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg IVD + granisetron 2mg + acetaminophen 500mg PO
    • 2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)

    • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.

    • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI

    • 2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI

    • 2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W

    • 2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)

    • 2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)

    • 2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)

    • 2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)

    • 2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)

    • 2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)

    • 2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)

    • 2019-12-06 ~ 2019-12-28 - capecitabine

    • 2019-06-12 - FOLFIRI + bevacizumab

    • 2019-05-28 - FOLFIRI + bevacizumab

    • 2019-05-07 - FOLFIRI + bevacizumab

    • 2019-04-20 - FOLFIRI + bevacizumab

    • 2019-04-03 - FOLFIRI + bevacizumab

    • 2019-03-16 - FOLFIRI + bevacizumab

    • 2019-03-02 - FOLFIRI + bevacizumab

    • 2019-02-17 - FOLFIRI + bevacizumab

    • 2019-02-03 - FOLFIRI

    • 2019-01-03 - FOLFIRI

    • 2018-06-08 ~ 2018-06-18: capecitabine

==========

2022-11-28

The control of blood sugar is better than it was during the last hospital stay. As far as the active prescription is concerned, there is no problem.

2022-11-09

The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.

2022-09-13

Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).

Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.

2022-07-22

Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).

There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.

2022-03-15

CT and MRI in mid January 2022 showed the disease progressed compared to previous images.

CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).

701459963

230321

[diagnosis]

  • Malignant neoplasm of left ovary
  • Left ovary mixed mucinous and aclear cell carcinoma, pT1c3N0M0, stage IC3, post debulking (ATH + BSO + BPLND + artial omentectomy) on 2022/11/18

[past history]

  • Past hx: denied
  • Surgical hx:
    • 2022/11/18 ebulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis
    • 2202/12/07 port implantaion, left cephalic vein

[allergy]

  • NKDA     

[family history]

  • denied family history

[exam findings]

  • 2023-02-18 SONO - abdomen
    • mild fatty liver
    • right renal cyst
  • 2023-02-16 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) Prolonged distal motor latency, decreased SAP amplitude, slowing sensory conduction velocity in bilateral median nerves. (2) Decreased CMAP amplitude in left median nerve. The F wave study showed no response in left median nerve. The H reflex was within normal limits. The QST study showed abnormal heat and cold sensation in upper and lower limbs.
    • Conclusion
      • The above finding suggest entrapment neuropathy in bilateral median nerves at wrist and small fiber disease. Advise clinical correlation.
  • 2023-02-09 Brainstem auditory evoked potentials, BAEP
    • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
    • Conclusion: This is a normal BAEP study.
  • 2023-02-16 Neurosonology
    • Mild atherosclerosis in left CCA bifurcation and left CCA.
    • Adequate total VA flow volume (234 ml/min).
  • 2023-01-27 MRI - brachial plexus
    • Indication
      • Ovary cancer
      • acute left upper arm pain and left upper limb weakness on 2022/11/21
      • had tenderness point
      • no trauma history
      • 2022/12/15 improving
    • Without- and with-contrast MRI of brachial plexus, including axial, coronal and oblique sagittal T1WI and T2WI (with 3 mm or 4 mm thickness) reveal:
      • Hypertrphic degeneration of C-spine, esp C5-6-7.
      • No abnormality along the course of left brachial plexus.
      • A well-defined non-enhancing cystic lesion infiltrating along muscles at left shoulder joint, including subacromion region, indicating degenerative joint disease.
      • S/P Port-A device at left chest wall.
    • IMP: No evidence of brachial plexus lesion. Cervical spondylosis.
  • 2023-01-27 MRI - C-spine
    • Findings:
      • General bulging disc with central focal protrusion causing mild spinal canal stenosis and bilateral mild neuroformainal narrowing at C4-5.
      • Decreased vertebral body height, end-plate degeneration, general bulging disc with central disc protrusion, posterolateral osteophytes and enlarged facets causing spinal canal stenosis, cord compression and bilateral moderate neuroforaminal narrowing at C5-6-7.
      • No intramedullary abnormality.
      • No abnormal enhancement.
    • IMP: Cervical spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp C5-6-7.
  • 2022-12-09 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) Prolonged distal motor latency in bilateral median nerves. (2) Marked decreased CMAP in left median nerve. (3) Slowing sensory conduction velocity in bilateral median nerve. The F wave study showed prolonged latency in left median nerve. The EMG study showed normal findings in left FDI, left brachioradialis and left biceps brachii muscle. The H reflx was normal.
    • Conclustion
      • The above findings suggest left median neuropathy, left cervical radiculopathy and entrapment neuropathy in right median nerve at wrist. Advise clinical correlation.
  • 2022-12-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 23 dB HL
    • bil normal to moderate SNHL (sensory neural hearing loss)
  • 2022-11-28 MRI - upper arm
    • Partial-thickness intrasubstance tear of supraspinatus tendon
    • Supraspinatus and infraspinatus tendinosis and calcific tendinitis
  • 2022-11-26 Shoulder LT
    • Calcified left rotator cuff tendinitis
  • 2022-11-26 CXR
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • a small nodular opacity over Lt midlung zone?
  • 2022-11-26 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2022-11-21 Patho - soft tissue tumor, extensive resection
    • Diagnosis:
      • Ovary, left, oophorectomy —- mucinous carcinoma with focal clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c2N0(if cM0), FIGO Stage IC2 or pStage IC, pT1c3N0(if cM0), FIGO Stage IC3; please correlate with the clinical presentation
      • Ovary, right, oophorectomy —- negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- negative for malignancy
      • Uterus, corpus, total hysterectomy —- negative for malignancy
      • Uterus, cervix, total hysterectomy —- negative for malignancy
      • Uterus, endometrium, total hysterectomy —- negative for malignancy
      • Omentum, omentectomy —- negative for malignancy
      • Lymph node, left iliac, dissection —- negative for malignancy (0/7)
      • Lymph node, left obturator, dissection —- negative for malignancy (0/10)
      • Lymph node, right iliac, dissection —- negative for malignancy (0/6)
      • Lymph node, right obturator, dissection —- negative for malignancy (0/7)
    • Gross description:
      • Procedure (select all that apply): debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND)
      • Specimen Integrity
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact
        • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size
        • F2022-00552
          • Greatest dimension (centimeters): 7.5 cm
          • Additional dimensions (centimeters): 7.3 x 2.8 cm
      • Specimen size:
        • S2022-20527
          • right ovary: 2.3 x 1.8 x 0.3 cm;
          • right tube: 5.6 cm in length and 0.5 cm in diameter;
          • left tube: F2022-00552: 4.6 cm in length and 0.3 cm in diameter;
          • uterus: 8.6 x 5.6 x 4.8 cm, 135 g; Cervix: 3.8 x 3.5 x 2.8 cm; Endometrial cavity: 4.0 x 3.8 x 0.2 cm; Several leiomyomas, measuring up to: 1.1 x 1.0 x 0.8 cm
          • omentum: 14.7 x 10.5 x 2.0 cm
      • Sections are taken and labeled as:
        • F2022-00552: Representative sections are taken and labeled as: FsA1-3, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: left fallopian tube; X2: adnexal soft tissue; X3-6: left ovary.
        • S2022-20527: A1: cervix; A2-3: endometrium; A4: leiomyoma; A5: right ovary and fallopian tube; A6: left adnexal soft tissue; A7: posterior wall; B1-2: omentum; C1-2: lymph node, left iliac; D1-2: lymph node, left obturator; E1-2: lymph node, right iliac; F: lymph node, right obturator.
    • Microscopic Description:
      • Histologic Type: Mucinous carcinoma with focal clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), WT-1(-), PR(-), Napsin A(focal +), p53(aberrant expression +)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System: G2: Moderately differentiated
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Cannot be determined
      • Peritoneal/Ascitic Fluid: N2022-04283: suspicious
      • Regional Lymph Nodes: left iliac: 0/7; left obturator: 0/10; right iliac: 0/6; right obturator: 0/7
      • Additional Pathologic Findings: Leiomyoma and adenomyosis are seen.
  • 2022-11-18 Body fluid cytology - ascites
    • suspicious for malignancy;
    • few clusters of suspicious cells with high nuclear/cytoplasmic ratio present.
  • 2022-11-18 Frozen section
    • Ovary, left, oophorectomy —- adenocarcinoma
  • 2022-11-17 Colonoscopy
    • Diverticulum, descending colon
    • Internal hemorrhoid
  • 2022-11-17 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade AEsophageal phleboectasia, middle esophagus
      • Superficial gastritis
    • Suggestion
      • No endoscopic evidence of primary malignancy in UGI tract
  • 2022-11-16 ECG
    • Sinus bradycardia
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-11-10 Gynecologic ultrasonography
    • suspected pelvis mass: 92 x 47 mm (RI: 0.38)
    • ascites

[surgical operation]

  • 2022-11-18 debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis

[chemotherapy]

  • 2023-03-20 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-02-24 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-02-07 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-01-18 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2022-12-28 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2022-12-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3

[note]

First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer

  • General principles
    • The standard approach to treatment for women requiring first-line chemotherapy for EOC is to use a platinum agent with a taxane. For women with optimally reduced disease (<1 cm of residual disease), there are two options: intravenous (IV) chemotherapy alone or a combination of IV and intraperitoneal (IP) chemotherapy (IV/IP therapy). Women with suboptimally reduced disease (≥1 centimeter of residual disease) are not candidates for IP therapy due to limited penetration into larger tumors. These women should therefore receive IV treatment.
  • Women with optimally cytoreduced disease
    • IV/IP therapy versus IV therapy alone
      • Comparative data
        • For women with optimally cytoreduced disease (no residual or less than 1 cm of residual disease) who have not received neoadjuvant treatment, IV/IP therapy is an appropriate option. Some UpToDate experts prefer IV/IP treatment for optimally cytoreduced disease, while others prefer IV therapy, particularly given that other treatment options including bevacizumab and maintenance therapy with PARP inhibitors are also often included.
      • Preferred IV/IP therapy regimen
        • The most commonly used intravenous/intraperitoneal (IV/IP) regimen comes from GOG 172 and consists of six cycles of
          • IV paclitaxel (135 mg/m2 over 24 hours) on day 1
          • IP cisplatin (100 mg/m2 in a liter of normal saline) on day 2
          • IP paclitaxel (60 mg/m2) on day 8
        • We typically use the above regimen, with the exception of reducing cisplatin to 75 mg/m2, which was the regimen used in GOG 252.
      • Preferred IV therapy regimen
        • For patients with optimally cytoreduced disease in whom intravenous (IV) therapy will be administered, choice of agents and scheduling is the same as for those with suboptimally cytoreduced disease, and is discussed below.
    • Incorporation of HIPEC
      • For patients who undergo neoadjuvant chemotherapy and have an optimal surgical result (ie, residual disease <1 cm), incorporation of HIPEC is discussed separately.
  • Women with suboptimally cytoreduced disease
    • For patients with suboptimally cytoreduced EOC (epithelial ovarian cancer), we suggest IV treatment rather than IV/IP therapy.
    • Choice of agents
      • For women requiring first-line chemotherapy for EOC, the standard IV regimen utilizes platinum and taxane agents. For select patients at higher risk of recurrence (eg, those with pleural effusions or ascites who lack a BRCA mutation), we suggest the addition of bevacizumab, which is administered with chemotherapy and continued as maintenance therapy.
      • Although cisplatin and/or docetaxel are sometimes used in this setting, we prefer carboplatin plus paclitaxel. Our rationale is based on the following:
        • We prefer carboplatin rather than cisplatin because multiple trials have consistently demonstrated that carboplatin produces equivalent response rates and survival outcomes to cisplatin, but is associated with less toxicity.
        • Although both paclitaxel and docetaxel (the most commonly used taxanes for EOC) can be administered along with carboplatin in this setting, we prefer paclitaxel because it is less myelosuppressive than docetaxel. However, a consideration between these two taxanes can be individualized based on their differing toxicities. For paclitaxel, these include a higher risk of neuropathy, myalgias, and weakness compared with docetaxel; for docetaxel, these include a higher risk of neutropenia, hypersensitivity reactions, and nausea and vomiting.
        • We prefer to treat for a maximum of six cycles rather than more because there are no data that treatment beyond six cycles improves outcomes, although further treatment increases the risk of treatment-related toxicities. The administration of further treatment for patients who respond (or do not progress) after six cycles of first-line therapy (ie, maintenance therapy) is covered below.

==========

2023-03-21

  • Some patients with type 1 or type 2 diabetes have a paradoxically high GFR early in their disease course (ie, “glomerular hyperfiltration”). Glomerular hyperfiltration is usually defined as GFR approximately 20 percent or more above that in age-matched, healthy controls without diabetes. In younger individuals, the usual threshold for hyperfiltration is considered 120 to 140 mL/min/1.73m2, whereas in older adults it may be closer to 100 to 120 mL/min/1.73m2. In studies of patients with diabetes that measured GFR, hyperfiltration was associated with greater risks of albuminuria progression and kidney function decline. The kidney protective effects of renin angiotensin system (RAS) and sodium-glucose cotransporter 2 (SGLT2) inhibitors are thought to be mediated, at least in part, by reductions in glomerular hyperfiltration.
    • 2023-03-15 eGFR 155.56
    • 2023-03-09 eGFR 134.22
    • 2023-02-22 eGFR 144.16
    • 2023-02-15 eGFR 151.57
    • 2023-02-07 eGFR 147.78
    • 2023-02-01 eGFR 128.28
    • 2023-01-17 eGFR 144.16
    • 2023-01-12 eGFR 155.56
  • No HbA1c readings or blood glucose levels are accessible in HIS5. It is advised to examine whether the patient has developed type 2 diabetes.

2022-12-29

  • According to the 2022-12-28 lab results, the readings were grossly within the normal range, and no dosage adjustment is necessary.
  • Primarily a distal sensory neuropathy, may occur with paclitaxel. Neuropathy can present as a mixture of paresthesias and dysesthesias, including burning, numbness, tingling, and shooting pains, typically in a stocking-glove distribution. Prior to the chemotherapy, 2022-12-09 nerve conduction velocity test suggested neuropathy, 2022-12-07 pure tone audiometry resulted bilateral normal to moderate sensory neural hearing loss. While severe symptoms are unusual, peripheral neuropathy often leads to subsequent dose reductions in many patients.
  • Carboplatin has also been associated with ototoxicity (1%, UpToDate). Although peripheral neuropathy occurs infrequently, the incidence of peripheral neuropathy is increased in patients >65 years of age and those who have previously received cisplatin treatment (not this case).
  • Please keep an eye out for signs of exacerbated adverse reactions as always.

700035817

230320

{not completed}

He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.

[exam findings]

  • 2023-03-16 CT - neck
    • Chief Complaints: Tongue swealling and left face redness
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
      • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • S/P tracheostomy.
      • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
  • 2023-03-16 CXR
    • S/P tracheostomy in place.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in bilateral lower lungs.
  • 2023-03-16, 2022-12-28, -12-10 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-01-05 CXR
    • S/p tracheal tube placement with its tip in place.
    • Tortous aorta with calcification is noted.
    • Senile fibrotic change is noted at lung fields.
  • 2022-12-22 CT - abdomen
    • History and indication: Respiratory failure
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastrostomy. Mild small bowel ileus.
      • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
      • Right adrenal nodule (9mm). Hyperplasia of left adrenal gland.
      • Right renal cysts (up to 8mm).
      • Normal appearance of liver, spleen, pancreas.
      • Wall thickening of gallbladder with stone (6mm).
      • Patency of portal vein.
      • Fracture of left femoral neck.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion. S/P tracheostomy in place. S/P foley catheter indwelling.
    • IMP:
      • S/P gastrostomy. Mild small bowel ileus.
      • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
      • Wall thickening of gallbladder with stone (6mm).
      • Fracture of left femoral neck.
  • 2022-12-22 Patho - colon biopsy
    • Colorectum, hepatic flexure, s/p biopsy(A) — Granulation tissue
    • Colorectum, hepatic flexure, s/p biopsy(B) — Hyperplastic polyp
  • 2022-12-16 CT - abdomen
    • The rectum and sigmoid colon show distension and hard feces retention. please correlate with clinical condition.
    • Chronic cholecystitis is highly suspected.
      • The differential diagnosis include gallbladder cancer.
      • Please correlate with sonography.
    • There are few soft tissue nodules in LLL of the lung.
      • Please correlate with chest CT.
    • Hyperplasia of bilateral adrenal gland are noted.
  • 2022-11-05 ECG
    • Sinus tachycardia
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-08-23 CT - neck
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • Presence of soft tissue swelling over the region of right face and neck with diffuse fat stranding.
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
    • Total occlusion of right ICA and upper-middle part of CCA.
    • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
    • Old right fronto-temporal insult with brain tissue loss due to ICH.
    • S/P tracheostomy in position.
    • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
    • Suggest clinical correlation and previous films comparison.
  • 2022-05-06 CT - neck
    • Indication: NPC cT4bNx, s/p CCRT + adjuvant PF
    • With and Without contrast Neck CT showed
      • s/p tracheostomy
      • s/p graft stent at the right CCA and right ICA with total occlusion.
      • soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
      • mucosal thickening in the bilateral frontal, bilateral ethmoidal, sphenoidal and bilateral maxillary sinuses. Wall thickening in the walls of the bialteral paranasal sinuses was noted.
      • old insult in the right parietal lobe
    • IMP: soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
  • 2022-05-05 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-04-16 Chest PA/AP view
    • S/P tracheostomy.
    • S/P port-A insertion via right subclavian vein.
    • Right lower lung infiltrates.
    • No cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2022-04-16 KUB
    • Calcifications in the pelvic cavity, could be due to phleboliths.
    • Non-specific bowel gas pattern.
    • Mild lumbar spondylosis.
    • Old fractures at left proximal femur.
  • 2022-01-13 Patho - polyps, inflammatory nasal/sinonasal
    • Labeled as “Granulation tissue at nasopharynx”, biopsy — benign squamous mucosa lined tissue with granulation tissue.
    • Labeled as “Granulation tissue at soft palate, poterior pharyngeal wall”, biopsy — squamous cell carcinoma, granulation tissue and necrotic tissue.
      • IHC stain: p16 (-).
    • Labeled as “Granulation tissue around stoma”, biopsy — necrotic tissue.
  • 2022-01-11 CT - CTA, brain (head, neck)
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
    • Total occlusion of right ICA and upper-middle part of CCA.
    • But seems with well blood collateral circulation to right ICA, MCA from left AcomA.
    • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
    • Old right fronto-temporal insult with brain tissue loss due to ICH.
    • S/P tracheostomy in position.
    • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
  • 2021-04-26 KUB
    • Osteopenia of the bony structure is noted.
    • The psoas shadow is clear.
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
    • Suggest clinical correlation
  • 2021-04-18 Sinuses
    • Water’s view of the paranasal sinuses showed
      • obliteration of the bilateral paranasal sinuses
      • no evidence of destructive bone lesions
  • 2021-04-18 Neck soft tissue
    • s/p tracheostomy
    • increased soft tissue thickness in the prevertebral soft tissue
    • s/p stenting at the right neck
  • 2021-04-18 CT - neck
    • s/p tracheostomy.
    • s/p stenting at the right ICA and right CCA with air in the luminal region
    • Diffuse soft tissue densities in nasalpharynx, oropharynx; and bilateral retropharyngeal, right carotid and right masticator spaces with diffuse subcutaneous fatty infiltrates and abscess formation in the right masticator space. Recurrent tumor with abscess, or stent extravasation? Suggest clinical correlation.
    • bilateral CPS.
  • 2020-12-06 CT - abdomen, pelvis
    • PE abdomen: Muscle guarding
    • Without contrast Abdomen CT showed
      • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys, except multiple GB stones, up to 22mm in the largest one.
      • gastrostomy
    • IMP: GB stones.
  • 2020-12-04 Bronchoscopy
    • Bronchitis
    • Tracheomalasia
    • Profuse purulent bronchorrhea s/p bronchial toilet
    • suspected nasopharyngeal tumor with nearly total obstruction
  • 2020-11-17 Nasopharyngoscopy
    • NPC s/p treatment
    • Trachea granulation
  • 2020-10-28 Whole body PET scan
    • In comparison with the previous study on 2018/12/19, glucose hypermetabolism in the right nasopharyngeal wall disappears, indicating NPC with good response to previous therapy. However, there is a new lesion of glucose hypermetabolism in the left vocal cord in this study, suggesting tumor recurrence with hypopharynx involvement.
    • Glucose hypermetabolism in the left level II cervical lymphh nodes, probably reactive change in response to locoregional inflammation.
    • Glucose hypermetabolism in the right pleura and right axillary lymph nodes, the nature is to be determined (inflammation/ infection process, NPC with distant metastasis, or others ?), suggesting follow-up.
    • Glucose hypermetabolism in the right neck, suggesting s/p tracheostomy with inflammation/infection process.
    • Glucose hypermetabolism in hepatic flexure of colon, bilateral shoulders, and left hip, probably benign in nature.
    • Nasopharyngeal cancer s/p treatment with tumor recurrence, rcT4NxM0-1, stage IVA at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-10-18 CT - neck
    • S/P tracheostomy.
    • S/P vascular stenting in right CCA with intraluminal and perivascualr air densities, suspected infection/inflammation.
    • R/O tumor recurrence in nasalpharynx, oropharynx and carotid and masticator spaces (mainly in right side), with cellulitis? Suggest clinical correlation.
    • Multiple enlarged lymph nodes in neck, mediastinum and right axillary regions.
  • 2020-09-09 CT - CTA, brain (head, neck)
    • Total occlusion from the right proximal CCA to the cavernous ICA with air in the stent graft. suspected inflammatory process.
  • 2020-05-27 CT - abdomen, pelvis
    • findings
      • There is an ill-defined mild poor enhancing lesion measuring 3.4 x 1.4 cm in S4 of the liver (Srs:3, Img:23) that may be abscess? please correlate with clinical condition and sonography.
      • There are several gallstones, the size < 1.8 cm), but no evidence of wall thickening, distension or surrounding fatty stranding.
      • Mild swelling of the pancreatic head is suspected. Please correlate with amylase and lipase level.
      • Left adrenal hyperplasia shows stationary.
      • Hyperdense hard Fecal material in the S-colon and rectum.
      • Status post feeding gastrostomy.
      • There is no focal abnormality in the biliary system, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no focal lesion in the mesentery and omentum.
    • IMP:
      • Liver abscess is suspected. please correlate with clinical condition and sonography.
  • 2020-01-06 Carotid angiography bilat
    • IMP: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
  • 2020-01-05 Embolization (TAE) - neuro
    • Indication: Massive bleeding from the oral cavity
    • Angiography of bilateral ECA shows oozing of the mucosa at right side supplied by branches of rigth ECA and active bleeding is found at left side by left ECA.
    • Embolization was done with fine gelatine sponge from bilateral ECAs till decreased blood flow.
  • 2020-01-05 Carotid angiography bilat
    • Right distal CCA blow-out with one pseudo-aneurysm formation. Suggest covered-stent insertion.
  • 2020-01-05 CT - lung/pleura (chest and upper abdomen) (with and without contrast)
    • Ind: hemoptysis, suspected lung hemorrhage, suspected NPC with tumor bleeding
    • Imp:
      • probably oozing or bleeding at hypopharyngeal region.
      • single nodule at left apical lung. suggest follow up.
      • s/p gastrostomy.
      • s/p tracheal tube placement with its tip in place.
    • 2019-11-25 Abdominal Ultrasonography
      • liver parenchyma disease/ incomplete exam of liver
      • gallstones, GB wall thickening
      • pancreas masked
      • spleen not seen
    • 2019-11-25 Phleborheograph, PRG
      • Venous thrombosis at right internal jugular vein; patent right external jugular vein; patent right subclavian vein.
    • 2019-11-13 CT - sinuses for navigator
      • Increased soft tissue in the bilateral posterior nostrils and the nasopharynx. Nature?
      • CPS
    • 2019-11-05 Nasopharyngolaryngoscopy
      • finding: bi sinus s/p FESS, right choana total synechiae (fibrosis between septum, right inferior T and nasal floor), left NP whitish mass, biopsy done
      • diagnosis
        • NPC s/p treatement
        • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
    • 2019-10-08 Nasopharyngolaryngoscopy
      • finding: right choana synechiae, left NP mass with whitish exudate coating
      • diagnosis
        • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
        • suggest debridement/excision of nasopharyngeal lesion + choana-plasy +- FESS for CPS
    • 2019-09-20 Repetitive stimulation test
      • Blink Reflex Studies
      • The repetitive stimulation study at frequency of 2Hz showed no typical decremental responses in the examined muscles.
      • Sympathetic Skin Response (SSR)
    • 2019-09-06 MRA - brain
      • General brain atrophy.
      • Hydrocephalus.
      • Bilateral chronic paranasal sinusitis.
      • Bilateral mastoiditis.
    • 2019-08-30 CT - brain
      • Brain atrophy.
      • Paranasal sinusitis, nasal polyps and mastoiditis.
      • Nasopharyngeal and oropharyngeal lesion. DDX: prolapse of nasal polyps, nasopharyngeal tumor. Suggest ENT check up.
    • 2019-07-26 MRI - nasopharynx
      • post-CCRT change with dissue swelling in the bilateral nasopharynx, oropharynx, amd hypopharyn; and anterior neck. Please f/u 3 months later.
    • 2019-05-24 CT - abdomen
      • Senile fibrotic change is noted at lung fields. Some bronchovascular bundle infiltration at right lower lobe is found.
      • Gallstones with borderline wall thickening but the GB is not distended.
    • 2019-05-15 Myocardial perfusion SPECT with persantin
      • Probably attenuating artifact or mild myocardial ischemia at the inferoseptal wall of LV.
      • No post-stress dilatation of the left ventricle.
    • 2019-05-15 Carotid phonoangiograph, CPA
      • Sonographic diagnosis:
        • Mild to moderate atherosclerosis in Rt CCA.
        • Imcomplete study due to poor temporal windows for transcranial insonation.
        • Partial venous thrombus formation or venous stasis was noted in Rt IVJ with blood flow.
        • Adequate total VA flow volume (126 ml/min), indicating absence of Vertebrobasilar insufficiency.
      • Advise clinical correlation.
    • 2018-12-20 MRI - nasopharynx
      • Image staging(AJCC,8th edition): NPC, T1N1Mx, stage II.
    • 2018-12-19 Whole body PET scan
      • Glucose hypermetabolism in the right nasopharyngeal wall, compatible with the primary lesion of nasopharyngeal cancer.
      • Glucose hypermetabolism in the right level II and III cervical lymph nodes, suggesting cancer with regional lymph node involvement.
      • Mild glucose hypermetabolism in the left level IIa cervical lymphh nodes, reactive change in response to locoregional inflammation may show such a picture.
      • Glucose hypermetabolism in both lobes of the thyroid gland, inflammatory change is more likely. Please correlate with other work-up studies if further evaluation is warranted.
      • Nasopharyngeal cancer, cT1N1M0, stage II (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2018-12-10 Surgical pathology level IV
      • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma
      • The sections show non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of sheets and scattered spindle-shaped neoplastic cells in lymphoid stroma.
      • IHC: CK(+), p63(+).

[consultation]

  • 2023-03-17 Ear Nose Throat

    • Q
      • This is a 68 years old man had history of (1) NPC cT4bNx, s/p CCRT + adjuvant PF, with long term ventilator status under hospice care, Diabetes mellitus, Hypertension, Reflux esophagitis and duodenal ulcer, Chronic obstructive pulmonary disease, Hypothyroidism, Right distal common carotid artery pseudoaneurysm status post transcatheter arterial chemoembolization and stent insertion, Old intracerebral hemorrhage, Old myocardial infarction, Right internal jugular vein thrombosis, Enlarged prostate.
      • This time he was admitted due to Tongue swealling and left face redness for 2 days.
      • CT done at ER reported:
        • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
        • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
        • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • Lab with leukocytosis and bandemia, admission under the impression of progression of NPC with deep neck infection with abscess formation, cannot rule out tumor necrosis.
      • Emperic treatment with brosym was prescribed. The patient’s family request for further surgical treatment for possible symptom relief.
      • We need your expertise for further evaluation of possibilites of surgical drainge of abscess, thank you!
    • A
      • 68 y/o man
        • NPC s/p treatment
        • Oropharyngeal cancer noted since 2022-01 (biopsy of oropharynx on 2022-01-12: squamous cell carcinoma)
        • No further treatment for oropharyngeal cancer
        • Neck CT on 2022-03-16 revealed loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • Suggest antibiotics teatment
        • I & D not recommended because the CT finding was related to his tumor necrosis with 2nd infection (I&D: Incision and Drainage)
        • I will discuss with his family
  • 2023-03-17 Infectious Disease

    • Q
      • Emperic treatment with brosym was prescribed.
    • A
      • This is a case of oropharyngeal & hypopharyngeal abscess with sepsis.
      • Hx NPC s/p op, C/T, ventilator dependent, DM, HCVD.
      • Antibiotcs with meropenem 1g iv q8h is suggested.
      • Please consider debridement.
      • Collect B/C and pus for culture.
      • Please adjust antibiotic according to culture results and clinical conditions.
    • 2021-12-08 ENT
      • Minimal oozing from tracheal wound
      • Portable fiber through tracheal tube: patent airway, no active bleeding site
      • Local treatment done
      • Suggestion:
        • Curam + Paran for Rt. facial cellulitis
        • ENT OPD f/u if needed
    • 2021-05-06 ENT
      • we had changed the trachea already this night but I could not help him to clean the cerumen because the patuient could noy obey our order and he is too heavy that the nurse was hard to move his head
      • we suggested back yo our OPD for crumen removed
    • 2021-05-03 Family Medicine
      • The patient is a case of NPC. This time, he was admitted due to deep neck infection with abscess formation. Due to poor prognosis, we were consulted for further evaluation.
      • When I visited, the patien lied on bed. I asked the nurse about the family’s decision for hospice care. The nurse said that the patient’s wife still need to take the message to other family members. And they didn’t make decision. As a result, I arranged hospice combine care for the patient.
      • Assessment
        • Indication for hospice combine care : NPC with severe infection
        • ECOG 4
    • 2021-04-19 Radiation Oncology
      • Q
        • This 67 year old man is a case of NPC, old CVA, tracheostomy with vewntilation. He suffer form deep neck infection with abscess formation. We need your expertise for pigtail drainage!
      • A
        • According to the clinical condition and imaging findings, drainage is indicated.
    • 2021-04-18 ENT
      • Impression: Deep neck infection with abscess formation, nasopharyngeal carcinoma.
      • Plan:
        • Surgical intervention at the moment is not appropriate owing to high mortality and morbidity rate.
        • Please arrange admission to INFECTION IPD for broad-spectrum antibiotic treatment.
      • Already told the patient to consider hospice care.
    • 2021-03-30 ENT
      • Local finding via portable fiberoscopy:
        • Bil. nasal mucopus and cannot see N-P well, favor post-RT CPS
        • Rt. auricle swelling and EAC cerumen impaction
        • Diffused redness and swelling of Rt. facial, neck and shoulder skin
      • Imp
        • Favor diffused soft tissue infection, suspected post-R/T caused poor circulation
      • Suggestion
        • Keep current Abx
        • If no improvement or even progression, may consider CT for r/o abscess formation
    • 2020-12-24 Rehabilitation
      • Assessment
        • Acute respiratory failure with ventilator support
        • NPC s/p CCRT with airway stenosis s/p tracheostomy
        • Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding s/p TAE with stent
        • COPD with AE
        • DM
        • HTN
        • old CVA with bedridden status
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength, remove endo tube
    • 2020-10-26 Radiation Oncology
      • Assessment: Non-keratinizing squamous cell carcinoma of the nasopharynx, stage cT1N1M0 (stage II), s/p CCRT.
      • Plan: There is no tissue proven of the suspicious area at the present. ENT further evaluation was suggested.
    • 2020-03-18 Mental Health
      • Psychiatric impression
        • Depressive DISORDER WITH SUICIDE ATTEMPT
        • ADJUSTMENT DISORDER WITH DEPRESSED MOOD,
      • Psychiatric history
        • This 66-year-old male patient was brought to this ER due to self-remove trachia this morning. According to his wife, notable depressed mood and insomnia with initial type since diagnosed with NPC. However, his depression was progressed in recent 3 months since he suffered form hemiparesis due to hemoregic stroke. He also note cooperative for rehabilitation and other treatment. Few and nearly no interpersonal interaction. Previosly, he had self-remove trachia during hospitalization.
        • GIVEN-UP COMPLEX, HELPLESSNESS AND HOPELESSNESS
      • Medical history:
        • Nasopharyngeal, left, non-keratinizing squamous cell carcinoma, cT1N1M0, stage II, with right neck LNs, s/p CCRT and Chemotherapy. Intake form grastostomy
        • Diabetes Mellitus type II.
        • Chronic obstructive pulmonary disease.
        • Right distal common carotid artery pseudoaneurysm status transcatheter arterial chemoembolization and stent on 2020/01/06.
      • Suggestion:
        • prevent suicide, well inform the risk and prevention to his family
        • emotional support
        • correct his medical problem as your expertise
        • may give Mirtapine 1# hs for his depression
        • arrange psychiatric OPD follow up
    • 2020-01-12 General and Gastroenterological Surgery
      • Inform the family members (his wife) of the CT results of the brain, and inform that if the anticoagulant continues to be used, it may aggravate the cerebral hemorrhage, but if the anticoagulant is not used, the stent placed in the aneurysm may be blocked.
    • 2020-01-07 Neurology
      • impression: left hemiplegia, suspect R hemisphere subcortical infarction
      • suggestion:
        • agree with current dual antiplatelet agent therapy if no contraindication such as active bleeding
        • arrange brain MRA (without contrast) for stroke survey (consider contrast enhancement for brain metastasis survey)
    • 2020-01-07 Family Medicine
      • When I visited patient, he lied on the bed and his consicousness was drowsy. Interminttent oozing from oral and trochea were found. Tachycardia was found (HR: 120-130/minute). Breathing sound showed no rhonchi or no wheezing. CT on 20200105 showed tumor local invasion and angiography on 20200106 showed no pneudoaneurym formation. Stent for carotid bleeding was done at that time. Due to NPC with local invasion and persisted bleeding, we will arrange hospice combine care for patient first. If his family prefer to receive palliative care, we will discuss with family about further management or PCU admission issue. If family still want to receive aggressive treatment/management, we will keep current combine care first.
    • 2020-01-07 Infectious Disease
      • Bleeding is the major problem now.
      • Despite there is leukocytosis, no definite infection is found at the present time.
      • Because of repeated embolization, temporary coverage of staphylococci, including MRSA/MRSE possibility, is acceptable.
      • Empirical anti-fungal therapy seems not necessary for him.
      • Please repeat CxR film to see if there is newly-developed pneumonia or not.
    • 2020-01-07 Radiation Oncology
      • We have arranged emergent angiography for this patient 20200106 19:00, which revealed right distal CCA blowout, with active bleeding from pseodoaneurysm. Two stents were placed crossing distal CCA and proximal ICA. No more active bleeding is noted after stenting.
      • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
    • 2020-01-07 ENT
      • Local finding: Oozing from oral cavity but cannot see the bleeding origin
      • No epistaxis nor bleeding from tracheostomy
      • s/p 10 pieces Bosmin gauze compression, but may still need TAE again
    • 2020-01-04 ENT
      • Scope: should suspect bleeding from tracheal or lung
        • Yellowish mass over bil. nasopharynx, suspected pus (CPS) or tumor
        • Cannot passed the scope into hypopharynx.
      • However, the patient was using tracheal tube “without” side hole -> less likely from nasal or oral cavity
      • Suggestion: consult chest men for lung CT or bronchoscopy
  • surgical operation

    • 2022-01-12
      • Surgery
        • debride the granulation tissue
        • change gastrostomy tube 20fr for him
      • Finding
        • grandulation tissue around the gastrostomy
    • 2022-01-12
      • Surgery
        • Stomaplasty    
        • Biopsy of oropharynx and nasopharynx mucosal lesion       
      • Finding
        • Granulation around the stoma except inferior part    
        • Yellowish semisolid necrotic substance at soft palate, posterior pharyngeal wall, and bilateral nasopharynx; Diffuse mucosal edema and touch bleeding was noted at above areas  
    • 2020-11-11 excision - granuloma around gastrostomy, easy bleeding(+), pain(+)
    • 2020-04-29 Stomaplasty
      • Surgery
        • Stomaplasty + Nasopharyngeal lesion biopsy
      • Finding
        • Stoma stenosis with granulation formation.
        • Whitish exudate like lesion at bilateral nasopharynx.
    • 2021-04-28
      • Surgery
        • Incision and drainage of right masticator space
      • Finding
        • Much bloody discharge and few pus over right masticator space
    • 2020-04-02
      • Surgery
        • laparoscopic gastrostomy
      • Finding
        • NPC
        • difficulty in NG tube insertion
    • 2020-01-06 Embolization (TAE) - neuro
      • Indication: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
      • TAE was done with two 8x50 mm stent graft (Viabahn Endoprothesis, overlapped on distal CCA), no more contrast leak after this procedure.
      • Imp: Post stent grafting of the large right CCA pseudoaneurysm.
      • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
    • 2019-11-20 Nasopharyngeal necrosis and right choana atresia
    • 2019-08-27 Tracheostomy for respiratory failure
      • neck shortness and stiffness, tracheostomy done with Shily #6
    • 2019-06-10 Jejunostomy - Nasopharyngeal cancer post op, for feeding jejunostomy creation
    • 2017-12-26 R’t soft palate tumor
      • 1.3x2mm granular lesion at right soft palate

==========

2023-03-17

[drug identification]

The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.

This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.

The medication will be sent back to the ward by an in-hospital porter.

2022-05-05

  • Lab data on 2022-05-04 showed PT 10.6 sec, INR 1.02, APTT 40.4 sec, Fibrinogen 474.5 mg/dL, D-dimer 982 ng/mL(FEU).
  • Aspirin, warfarin, vitamin K antagonists, DOACs records found in NHI PharmaCloud.
  • Tranexamic acid 500mg IVD Q8H has been prescribed since 2022-05-05.
  • Hemoptysis no longer appears in the problem list. No issue with current medication.

701252793

230320

[diagnosis] - 2023-03-17 admission note

  • Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
  • Neoplasm of uncertain behavior of brain, unspecified
  • Other cerebrovascular disease
  • Dizziness and giddiness
  • Other localized visual field defect, unspecified eye
  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Personal history of other infectious and parasitic diseases
  • Chronic obstructive pulmonary disease, unspecified
  • Gout, unspecified

[exam findings]

  • 2023-02-07 MRI - brain
    • No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
  • 2022-10-12 MRI - brain
    • Clinical information: Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma. Primary NHL (Diffuse large B cell lymphoma) of brain
    • Findings
      • Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm).
      • Prominent peri-tumoral edema over left thalams and temporal lobe.
  • 2022-07-13 Body Fluid Cytology - CSF
    • Negative
    • Smears show some small lymphocytes, plasma cells, and monocytes.
  • 2022-07-12 Whole body PET scan
    • A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
    • Mild glucose hypermetabolism in a focal area in the left anterior upper chest wall. Inflammation may show this picture.
    • Increased FDG accumulaton in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2022-07-11 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 60 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2022-07-09 CXR
    • Atherosclerotic change of aortic arch
  • 2022-07-04 CT - lung/mediastinum/pleura
    • No tumor or LAPs in the neck, chest, and upper abdomen.
  • 2022-07-04 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-06-23 Patho - brain biopsy
    • Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
    • Immunohistochemical stain profiles:
      • CD20(diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-).
      • MUM-1(+), C-MYC(+)
  • 2022-06-23 Frozen Section
    • Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm
  • 2022-06-21 CT - brain for navigator
    • Findings
      • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt.
      • Mild dilated right lateral ventricle.
    • Impression:
      • intra-axial tumor, d/d lymphoma or high grade glioma.
  • 2022-06-20 MRA - brain
    • Left temporal lobe-basal ganglion tumor with mass effect.
    • D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
  • 2021-04-29 SONO - kidney
    • Right renal stone 0.44 cm
  • 2020-09-21 Bronchodilator Test
    • diagnosis: COPD
    • conclusion: normal spirometry

[consultation]

  • 2022-10-20 Radiation Oncology
    • Q
      • The 56 y/o man has primary brain diffuse large B cell lymphoma, CD20 (diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-). Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions).
      • Due to brain lesion in progress, so we need your help for RT assessment. Thanks!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to CNS lymphomas s/p chemotherapy.
        • PI: The patient has primary brain diffuse large B cell lymphoma, Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions) s/p chemotherapy (2022-07-14 ~ 2022-10-21). Due to brain tumor progression, he was referred for radiotherapy.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Previous RT Hx: (-)
      • O: ECOG: 1
        • PE: meck and bil SCF: neg; no motor dysfunction.
        • CXR (2022-06-20): Clean lung fields based on plain image. Normal shape and size of heart. No abnormal mediastinal interfaces, stripes, and lines. Normal appearance of both hila. Costophrenic angles are preserved. Unremarkable of visible trachea
        • MRI of brain (2022-06-20): Left temporal lobe - basal ganglion tumor with mass effect. D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
        • Operation (2022-06-23): Left periventricular tumor for stereotactic biopsy. [Finding]: 1. An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process.
        • Pathology (S2022-10048, 2022-06-29): Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
        • CT scan of lung (2022-7-4): no tumor or LAPs in the neck, chest, and upper abdomen.
        • Pathology (S2022-11023, 2022-07-12): Bone marrow, iliac, biopsy — Negative for malignancy.
        • PET (2022-07-12): A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
        • CSF (2022-07-13): negative
        • MRI of brain (2022-10-12): 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), Left temporal lobe-basal ganglion (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe.
      • A: Diffuse large B cell lymphoma of the left temporal lobe-basal ganglion area, Lugano stage 1E, s/p chemotherapy, with gross residual tumor.
      • P: Radiotherapy is indicated for this patient with the following indicators: gross residual tumor
        • Goal: curative
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 3060cGy/17 fractions of the whole brain, and 4500cGy/25 frcations of the CNS lymphoma area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-10-26.
  • 2022-07-20 Nephrology
    • Q
      • The 55 y/o man has primary CNS lymphoma post HD-MTX and Mabtherapy treatment.
      • Due to AKI with elevated P and Mg, but no oliguria or SOB, so we need your help for management. Thanks!
    • A
      • Lab:
        • BUN 96, Cr 1.09 -> 9.71, Na 133, K 3.5, Mg 3.2, P 7.6, Ca 2.3
      • Impression:
        • AKI stage 3 suspect methotrexate induced
        • primary CNS lymphoma post HD-MXT and Mabthera
      • Suggestion
        • check urinalysis
        • check vein gas
        • IV hydration with urinary alkalinzation; could also prescribe furosemide
        • Follow up VBG and urinalysis in the following day
        • check I/O and body weight qd
        • avoid nephrotoxic agents
        • indication of dialysis has been explained to the patient and family.
      • We will follow up the case. Thank you very much for your consultation.
  • 2022-07-11 Ophthalmology
    • Q
      • The 55 y/o man has primary CNS lymphoma with right eye blurred vision, so we need your help for management.
    • A
      • O
        • bv od > os, no floaters ou
        • oph denied
        • BCVA od 0.2(0.4x-1.25/-1.50x175) os 0.2(0.2x-0.75/-2.50x180)
        • PT 20/20
        • k clear ou
        • ac d/cl ou
        • lens clear ou
        • conj np ou
        • f’d c/ d 40% ou, media clear no vitritis ou
      • A
        • no ocular involvement ou currently
      • P
      • suggest control underlying disease+inform the symptoms/ signs and opd f/u afterward
  • 2022-06-20 Neurosurgery
    • Q
      • Stroke symptoms (sudden slurred speech/unilateral limb paresthesia/sudden visual impairment) > symptom onset more than 4.5 hours or relieved, right limb and visual field incoordination for two weeks
    • A
      • A case of 55 y/o male; progressive headache (night pain)/blurred vision/gait disturbance for 2 weeks;
      • Drug hx: nil
      • A brain MRI/MRA showed A well-defined irregular-shaped mass with T1-hypointensity, T2-hyperintensity, diffusion restriction and vivid enhancement involving left deep temporal lobe and basal ganglion, associating with perifocal white matter edema and causing mass efect on laterla ventricles and midline structures. Lymphoma is first considered. D/D: metastases, GBM.
      • P: admit for tumor survey; Stereotactic biopsy indicated; HIV?; Explained;

[surgical operation]

  • 2022-06-23
    • Surgery
      • Left periventricular tumor for stereotactic biopsy
    • Finding
      • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process
      • 3 strips/ 2 targets were apllied for tumor biopsy;
      • Frozen section: lymphocyte/ vascular structure/ inflammation cell?; Favor malignancy. Perminent report will be followed;
      • Culture also sent.
    • Remark: FROZEN SECTION INITIAL DIAGNOSIS: Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm

[C/T history]

C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.

C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.

C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.

2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.

He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.

C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.

This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.

[chemoimmunotherapy]

  • 2023-03-17 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
  • 2023-01-06 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2

    • 2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

[note]

methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)

  • Dosing: Adult
    • Primary CNS lymphoma, newly diagnosed (off-label use):
      • IV:
        • 8 g/m2 over 4 hours (followed by leucovorin rescue) every 14 days until complete response or a maximum of 8 cycles; if complete response, follow with 2 consolidation cycles at the same dose every 14 days (with leucovorin rescue), followed by 11 maintenance cycles of 8 g/m2 every 28 days (with leucovorin rescue) (Batchelor 2003)
      • R-MPV regimen:
        • 3.5 g/m2 over 2 hours on day 2 every 2 weeks (in combination with rituximab, vincristine, procarbazine, and leucovorin [with intra-Ommaya methotrexate 12 mg between days 5 and 12 of each cycle if positive CSF cytology]) for 5 to 7 induction cycles followed by reduced-dose whole brain radiotherapy and then cytarabine (Morris 2013; Shah 2007) or autologous stem cell transplant (Omuro 2015)
      • R-MP regimen (patients >=65 years of age):
        • 3 g/m2 over 4 hours on days 2, 16, and 30 of a 42-day cycle (in combination with rituximab, procarbazine, and leucovorin) for 3 cycles (Fritsch 2017)
      • MT-R regimen:
        • 8 g/m2 once every 2 weeks (adjusted for creatinine clearance and in combination with leucovorin, temozolomide, and rituximab) for 7 doses, then followed by high-dose consolidation chemotherapy (Rubenstein 2013)
        • 3.5 g/m2 on weeks 1, 3, 5, 7, and 9 (in combination with leucovorin, temozolomide, and rituximab), followed by whole-brain radiotherapy and then post-radiation temozolomide (Glass 2016).
  • Dosing: Kidney Impairment: Adult
    • Regimen-specific dosage adjustments:
      • Primary CNS lymphoma, high dose methotrexate (usual methotrexate dose: 8 g/m2 over 4 hours with leucovorin rescue [Gerber 2007]); CrCl is measured or can be calculated using the Cockcroft-Gault equation (Gerber 2007): IV:
        • CrCl >=100 mL/minute: No methotrexate dosage adjustment necessary.
        • CrCl 50 to 99 mL/minute: Calculate dose using percentage reduction of CrCl below 100 mL/minute. Example: If CrCl is 80 mL/minute, adjust dose to 0.8 x 8 g/m2 = 6.4 g/m2.
        • CrCl <50 mL/minute: Avoid methotrexate use.

leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)

  • Dosing: Adult
    • Methotrexate-rescue, high-dose methotrexate:
      • Initial: Oral, IM, IV: 15 mg (~10 mg/m2); start 24 hours after beginning methotrexate infusion; continue every 6 hours for 10 doses, until methotrexate level is <0.05 micromolar. Monitor hydration and electrolyte status, as well as urine alkalinization. Adjust dose per institutional protocol or as follows:
        • Normal methotrexate elimination (serum methotrexate level ~10 micromolar at 24 hours after administration, 1 micromolar at 48 hours, and <0.2 micromolar at 72 hours):
          • Oral, IM, IV: 15 mg every 6 hours for 60 hours (10 doses) beginning 24 hours after the start of methotrexate infusion.
        • Delayed late methotrexate elimination (serum methotrexate level remaining >0.2 micromolar at 72 hours and >0.05 micromolar at 96 hours after administration):
          • Continue leucovorin calcium 15 mg (oral, IM, or IV) every 6 hours until methotrexate level is <0.05 micromolar.
        • Delayed early methotrexate elimination and/or acute renal injury (serum methotrexate level >=50 micromolar at 24 hours, or >=5 micromolar at 48 hours, or a doubling of serum creatinine level at 24 hours after methotrexate administration):
          • IV: 150 mg every 3 hours until methotrexate level is <1 micromolar, then 15 mg every 3 hours until methotrexate level is <0.05 micromolar.
    • Methotrexate overdose, inadvertent:
      • Note: Begin as soon as possible after overdose.
      • Oral, IM, IV: 10 mg/m2 every 6 hours until the methotrexate level is <0.01 micromolar. If serum creatinine is increased >50% above baseline 24 hours after methotrexate administration, if 24 hour methotrexate level is >5 micromolar, or if 48 hour methotrexate level is >0.9 micromolar, increase leucovorin dose to 100 mg/m2 IV every 3 hours until the methotrexate level is <0.01 micromolar.
    • Methotrexate overexposure, high-dose methotrexate:
      • Leucovorin nomogram dosing for high-dose methotrexate overexposure (off-label dosing; generalized dosing derived from reference nomogram figures, refer to each reference [Bleyer 1978; Bleyer 1981; Widemann 2006] or institution-specific nomogram for details):
        • At 24 hours:
          • For methotrexate levels of >=100 micromolar at ~24 hours, leucovorin calcium is initially dosed at 1,000 mg/m2 IV every 6 hours.
          • For methotrexate levels of >=10 to <100 micromolar at 24 hours, leucovorin calcium is initially dosed at 100 mg/m2 IV every 3 or 6 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 24 hours, leucovorin calcium is initially dosed at 10 mg/m2 IV or orally every 3 or 6 hours.
        • At 48 hours:
          • For methotrexate levels of >=100 micromolar at 48 hours, leucovorin calcium is dosed at 1,000 mg/m2 IV every 6 hours.
          • For methotrexate levels of >=10 to <100 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 3 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 6 hours or 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
        • At 72 hours:
          • For methotrexate levels of ≥10 micromolar at 72 hours, leucovorin calcium is dosed at 100 to 1,000 mg/m2 IV every 3 to 6 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
          • For methotrexate levels of ~0.1 to 1 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally every 3 to 6 hours.
        • If serum creatinine is increased >50% above baseline, increase the standard leucovorin calcium dose to 100 mg/m2 IV every 3 hours, then adjust according to methotrexate levels above.
        • Follow methotrexate levels daily, leucovorin calcium may be discontinued when methotrexate level is <0.1 micromolar.
        • Some regimens use the following equation when calculating the leucovorin calcium dose (if the methotrexate plasma concentration is >5 micromolar) (Ramsey 2018):
          • Plasma methotrexate concentration (micromolar) x body weight (kg)
  • Warnings/Precautions
    • Disease-related concerns:
      • Anemias: Leucovorin is inappropriate treatment for pernicious anemia and other megaloblastic anemias secondary to a lack of vitamin B12; a hematologic remission may occur while neurologic manifestations progress.
      • Renal impairment: Leucovorin is excreted renally; the risk for toxicities may be increased in patients with renal impairment.
    • Concurrent drug therapy issues:
      • Fluorouracil: Leucovorin may increase the toxicity of 5-fluorouracil; deaths from severe enterocolitis, diarrhea, and dehydration have been reported (in elderly patients); granulocytopenia and fever have also been reported.
      • Sulfamethoxazole-trimethoprim: The combination of leucovorin and sulfamethoxazole-trimethoprim for the acute treatment of Pneumocystis jirovecii pneumonia in patients with HIV infection has been reported to cause increased rates of treatment failure.
    • Other warnings and precautions:
      • Folic acid antagonist overdose: When used for the treatment of accidental folic acid antagonist overdose, administer as soon as possible.
      • Methanol toxicity: Leucovorin is the reduced form of folic acid; leucovorin is rapidly converted to tetrahydrofolic acid derivatives, which are the storage forms of folate in the body. Because leucovorin does not require metabolic reduction, it is the preferred form of folate in the treatment of methanol toxicity. Administration during methanol toxicity is especially important in patients with chronic alcohol use disorder as these patients may have chronic folate deficiency. Clinicians should note that leucovorin is an adjunctive therapy and should never be used as the sole intervention in the management of methanol toxicity (AACT [Barceloux 2002]).
      • Methotrexate overdose: When used for the treatment of a methotrexate overdose, administer IV leucovorin as soon as possible. Monitoring of the serum methotrexate concentration is essential to determine the optimal dose/duration of leucovorin; however, do not wait for the results of a methotrexate level before initiating leucovorin. It is important to adjust the leucovorin dose once a methotrexate level is known. The dose may need to be increased or administration prolonged in situations in which methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.
      • Methotrexate rescue therapy: Methotrexate serum concentrations should be monitored to determine dose and duration of leucovorin therapy. Dose may need to be increased or administration prolonged in situations where methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.

==========

2023-03-20

  • The patient’s height is 175cm, weight is 80kg, and his lab results from 2023-03-20 showed serum Cre 1.38mg/dL, eGFR 56.65, and CrCl 63~68mL/min.
  • The recommended dosing for methotrexate in adult patients with CNS lymphoma whose CrCl is 50 to 99 mL/minute is to calculate the dose using the percentage reduction of CrCl below 100 mL/minute. For example, if CrCl is 65 mL/minute, the dose should be adjusted to 0.65 x 8 g/m2 = 5.2 g/m2.

2023-02-20

  • The patient’s serum creatinine levels have decreased to nearly the upper limit of normal.
    • 2023-02-02 Creatinine 1.30 mg/dL
    • 2023-01-20 Creatinine 1.54 mg/dL
    • 2023-01-16 Creatinine 1.41 mg/dL
    • 2023-01-13 Creatinine 1.95 mg/dL
    • 2023-01-10 Creatinine 2.09 mg/dL
    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL

2023-01-10

  • Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.

    • 2023-01-10 Creatinine 2.09 mg/dL
    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL
    • 2023-01-10 eGFR 35.09
    • 2023-01-09 eGFR 36.50
    • 2023-01-08 eGFR 37.13
    • 2023-01-07 eGFR 57.61
    • 2023-01-06 eGFR 81.22
    • 2023-01-10 BUN 27 mg/dL
    • 2023-01-09 BUN 27 mg/dL
    • 2023-01-08 BUN 26 mg/dL
    • 2023-01-07 BUN 21 mg/dL
    • 2023-01-06 BUN 17 mg/dL
  • The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.

  • It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.

  • Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.

  • An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.

2023-01-09

  • Lab data indicated that the patient’s renal function is deterioating

    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL
    • 2023-01-09 eGFR 36.50
    • 2023-01-08 eGFR 37.13
    • 2023-01-07 eGFR 57.61
    • 2023-01-06 eGFR 81.22
    • 2023-01-09 BUN 27 mg/dL
    • 2023-01-08 BUN 26 mg/dL
    • 2023-01-07 BUN 21 mg/dL
    • 2023-01-06 BUN 17 mg/dL
  • In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.

  • Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.

  • Serum MTX levels are declining at an apparent rate.

    • 2023-01-08 22:39 3.549 umol/L
    • 2023-01-07 22:36 17.473 umol/L
      • ref Toxic:
        • 24 hr > 10 umol/L
        • 48 hr > 1 umol/L
        • 72 hr > 0.1 umol/L
  • If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.

2022-07-20

  • The dosage of leucovorin 200mg Q6H used immediately following methotrexate has been adjusted to 400mg Q6H as of 2022-07-20. Leucovorin is excreted renally, however there are no dosage adjustments provided in manufacturer’s labeling for kidney impairment patients.
  • Items in the active prescription that should be addressed if kidney function is altered.
    • Keppra (levetiracetam)
      • The manufacturer’s labeling recommends estimating CrCl using the Cockcroft-Gault formula adjusted for BSA as follows: CrCl (mL/minute/1.73 m2) = CrCl (mL/minute)/BSA (m2) x 1.73.
        • CrCl 80 to 130 mL/minute/1.73 m2: 500 mg to 1.5 g every 12 hours.
        • CrCl 50 to <80 mL/minute/1.73 m2: 500 mg to 1 g every 12 hours.
        • CrCl 30 to <50 mL/minute/1.73 m2: 250 to 750 mg every 12 hours.
        • CrCl 15 to <30 mL/minute/1.73 m2: 250 to 500 mg every 12 hours.
        • CrCl <15 mL/minute/1.73 m2: 250 to 500 mg every 24 hours (expert opinion).
    • Baraclude (entecavir)
      • Daily-dosage regimen preferred.
        • CrCl >=50 mL/minute: No dosage adjustment necessary.
        • CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.
        • CrCl 10 to <30 mL/minute: Administer 30% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 72 hours.
        • CrCl <10 mL/minute: Administer 10% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 7 days.
    • Furosemide
      • eGFR >30 mL/minute/1.73 m2: No dosage adjustment necessary.
      • eGFR <=30 mL/minute/1.73 m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >160 to 200 mg IV (or oral equivalent) are unlikely to result in additional diuretic effect (Brater 2011).
  • CrCl is 10 mL/min and eGFR is 7 mL/min for this patient based on Cockcroft-Gault formula, CKD-EPI equation and 2022-02-20 updated lab data.

701469357

230320

[lab data]

2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml

[exam findings]

  • 2023-03-12 CT - abdomen
    • Clinical history: 51 y/o male patient with cough, headache, chills, fever since this morning, mild nausea, loose stool
    • With and without contrast enhancement CT of abdomen - whole:
      • S/P feeding jejunostomy.
      • Thickening wall at the middle/distal third esophagus, c/w esophageal cancer, with ulceration at left lateral wall with adjacent lung consolidation.
      • Left pleural effusion.
      • There are enlarged lymph nodes in bilateral SCF, pretracheal, subcarina, around GE junction, r/o metastatic lymph nodes.
      • Left renal cyst, 0.8cm.
      • Unremarkable change of the liver, spleen, pancreas and right kidney.
    • Impression:
      • S/P feeding jejunostomy.
      • Esophageal cancer with ulceration and adjacent left lung consolidations, left pleural effusion.
      • Multiple metastatic lymph nodes in lower neck, mediastinum and upper abdomen.
  • 2023-03-12 CXR
    • S/P port-A insertion via left subclavian vein.
    • Increased bilateral lung markings.
    • No cardiomegaly.
    • Thoracic spondylosis.
  • 2023-02-17 Patho - gingival/oral mucosa biopsy
    • Diagnosis:
      • Uvula, wide excision (S2023-2822A) with frozen section (F2023-65) — poorly differentiated carcinoma and sarcomatoid carcinoma.
      • Hypopharyngeal tumor, wide excision (S2023-2822B) — squamous cell carcinoma in situ (CIS), < 1 mm from unspecified margin.
      • Uvula: pT1 pNx (if cM 0); pStage: I.
      • Hypopharynx: pTis pNx (if cM0); pStage: 0.
    • Macroscopic examination
      • Surgical Procedure(s): uvula: wide excision with frozen section. Hypopharynx: wide excision.
      • Specimen Type:
        • Main location: S2023-2822A: uvula; B: hypopharynx.
        • Other part(s) included: F2023-00065A: posterior margin; B: anterior margin.
        • Lymph node dissection: no.
      • Specimen Integrity: intact
    • Microscopic examination
      • Histologic Type: 01: uvular tumor: poorly differentiated carcinoma and sarcomatoid carcinoma. 02. hypopharyngeal tumor: carcinoma in situ (CIS).
      • Histologic Grade: 01: uvular tumor: G3: Poorly differentiated
      • Microscopic Tumor Extension: (specify) submucosa.
      • Margins (obtained from the main resection specimen):
        • Margins uninvolved by invasive carcinoma, uvular tumor:
          • Distance from closest margin: gin and posterior margin. 4 mm. Anterior margin and posterior margin. NOTE: This distance does not include the size of frozen section specimens.
        • Margins uninvolved by squamous cell carcinoma in situ (left hypopharynx)
          • Distance from closest margin: 1 mm. Unspecified margin
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: no lymph node submitted.
  • 2023-02-11 MRI - larynx
    • p16(+) Oropharnx
      • Impression (Imaging stage): T: 0(T_value) N: 2c(N_value) M: 0(M_value) STAGE: IVA(Stage_value)
  • 2023-02-08 Nasopharyngoscopy
    • whitish lesion over posterior side of uvula, smooth NPx, granular lesion over left hypopharynx
  • 2023-02-04 MRI - brain
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2023-02-04 Pure Tone Audiometry
    • PTA:
      • Reliability FAIR
      • Average RE 38 dB HL, LE 43 dB HL
      • Bil normal to moderatly severe SNHL
  • 2023-02-03 Whole body PET scan
    • Glucose hypermetabolism involving the middle to lower portions of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a left upper paratracheal lymph node, some bilateral supraclavicular lymph nodes and a lymph node in the upper abdomen near EG junction. Metastatic lymph nodes may show this picture.
    • Mild glucose hypermetabolism in a focal area in the middle lobe of right lung. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Glucose hypermetabolism in the uvula, hypopharynx, nasopharynx, bilateral parotid glands, some bilateral upper neck lymph nodes, soft palate and bilateral tonsils. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-02-02 Tc-99m MDP whole body bone scan
    • Increased activity in the lower T-spines and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2023-02-02 Patho - larynx biopsy
    • Labeled as “hypopharynx”, biopsy — squamous cell carcinoma in situ (CIS).
  • 2023-02-02 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “uvula”, bronchoscopic biopsy — Sarcomatoid carcinoma.
    • Section shows diffuse infiltration of spindle shaped neoplastic cells.
    • IHC stain: Vimentin (diffuse +), CK (focal +), p16 (-).
  • 2023-02-01 Patho - esophageal biopsy
    • Soft palate, left, biopsy — Squamous cell carcinoma in situ
  • 2023-02-01 Cardiopulmonary Exercise Testing
    • summary:
      • low exercise capacity ( VO2 75%, WR 76%)
      • low stroke volume response during exercise
      • normal HR response slope
      • normal ventilatory function ( FVC 102%, FEV1 94%)
      • No SpO2 desaturation during exercise
      • Poor expiratory muscle strength (MIP 77%, MEP 51%)
      • Health-related quality of life, CAT= 0, good
    • suggestions:
      • treat underlying condition
      • for low stroke volume response, suggest to intake adequate fluid, may survey cardiac function
      • arrange pulmonary rehab with exercise training after operation
      • low risk for operation
  • 2023-01-30 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-01-30 Patho - esophageal biopsy
    • Esophagus, 30 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated (G2)
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
  • 2023-01-28 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Highly suspected esophageal cancer, M-L/3, s/p biopsy
      • Incomplete study
    • Suggestion
      • Admission for parenteral nutrition and staging.
      • Watch out for refeeding syndrome.

[radiotherapy]

[chemotherapy]

  • 2023-03-16 - cisplatin 80mg/m2 130mg NS 500mL 4hr + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701473264

230316

[drug interaction]

  • Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.

  • Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.

700180610

230315

[exam findings]

  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 29) / 76 = 61.84%
      • M-mode (Teichholz) = 61
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2023-02-01 whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-01-30 Her-2/neu in situ hybridization
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION: BREAST
      • Negative: There is NO amplification of HER2 detected
      • METHOD AND DETAILS:
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 gene copy signal per cell: 1.8
        • Average number of CEP17 gene copy signal per cell: 2
        • HER2/CEP17 ratio: 0.9
        • Heterogeneous signals: Absent
        • Origin slide and block number: S2023-1401
        • Specimen: Formalin-fixed paraffin embedded breast tumor
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
      • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
        • Amplified:
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
        • Not amplified:
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION : LYMPH NODE
      • Negative: There is NO amplification of HER2 detected
      • METHOD AND DETAILS:
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 gene copy signal per cell: 1.8
        • Average number of CEP17 gene copy signal per cell: 2
        • HER2/CEP17 ratio: 0.9
        • Heterogeneous signals: Absent
        • Origin slide and block number:S2023-1402
        • Specimen: Formalin-fixed paraffin embedded breast tumor
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
      • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
        • Amplified:
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
        • Not amplified:
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
  • 2023-01-30 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
  • 2023-01-30 Patho - lymphnode biopsy
    • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
    • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
  • 2023-01-30 CT - chest
    • Indication: Unspecified lump in breast
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images, and oblique sagittal reconstructed images of the Rt breast shows:
      • chest wall: a large Rt breast solid soft-tissue tumor (93mm in longest axial dimension) with surrounding linear opacities (lymphatic drainage) and skin involvement, and many metastatic lymph nodes at Rt axilla.
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: no enlarged LN or mass.
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Visible abdominal contents: a low density focus (24mm) in the uterus, cystic lesion or necrotic myeoma.
        • mltiple stones with collapsed gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. no ascites..
      • Visualized bones: unremarkable.
    • Impression:
      • Rt breast cancer with Rt axillary LNs metastasis T4N1
  • 2023-01-20 SONO - breast
    • Findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • right breast huge tumor, with skin involvement, heteogenous, > 10cm, favor malignancy
        • LAP(+)
    • Diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • Treatment
      • Core-needle biopsy
    • Suggestion and Plan
      • Regular OPD follow-up
      • BI-RADS 5 - Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[chemotherapy]

  • 2023-03-14 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-20 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02

[assessment]

  • On 2023-01-30, the Her-2/neu in situ hybridization results indicated a negative status for both breast and lymph nodes.
  • On 2023-03-02, a grade 4 neutropenia event was observed in the patient with a WBC count of 930/uL and Neutrophil count of 18%. Following the administration of three consecutive days of lenograstim since that day, no further episodes of neutropenia have been observed up to the present time.
  • Please prescribe Baraclude (entecavir) 0.5mg tablets, one tablet daily, for the patient’s underlying hepatitis B virus infection.

700541242

230315

{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}

[diagnosis] - 2023-02-04 discharge note

  • Gastric  antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy
  • Hepatits B, anti-HBC:positive

[past history]

  • Hypertension
  • right shoulder s/p operation 7+ years ago at NTUH                                        

[allergy]

  • NKDA                             

[family history]

  • Denied family history of cancer and mental diseases.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-01-25 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at left brachiocephalic vein
    • Emphysematous change over both lungs.
    • Osteopenia of the bony structure is noted.
  • 2023-01-25 CT - abdomen
    • s/p subtotal gastrectomy.
    • Minimal ascites in the abdominal cavity is found.
  • 2023-01-25 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-01-02 CT - abdomen
    • History and indication: gastric cancer wt peritoneal seeing, pT4aN0M1, stage IV
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastric operation.
      • Bronchiectasis at RML, RLL and LLL.
      • Retroversion of uterus.
      • Atherosclerosis of aorta.
    • IMP:
      • S/P gastric operation. No evidence of tumor recurrence.
      • Bronchiectasis at RML, RLL and LLL.
    • 2023-01-02 CXR
      • Borderline cardiomegaly
      • Scoliosis of the T-spine with convex to right side.
    • 2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30 Body fluid cytology - ascites and others
      • Negative
    • 2022-08-01, -07-29, -07-27, -07-26, -07-24 CXR
      • Ground glass opacities in bil. lungs.
    • 2022-07-24 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Suboptimal study due to much blood and blood clot were noted upon entering stomach.
        • Post subtotal gastrectomy with Billroth II anastomosis
        • Suspicious gastrojejunal anastomosis site ulcers, Forrest calssification IIa and Ib, s/p hemostasis with submucosal epinephrine injection and clipping
      • Suggestion
        • NPO
        • High dose PPI use
        • suggest second-look endoscopy
    • 2022-07-20 CXR
      • Pneumoperitoneum.
      • Right catheterization to SVC in position.
      • Left catheterization to SVC in position.
      • S/P NG tube indwelling.
      • Ground glass opacity in bilateral lower lungs and RUL.
      • Blunted bilateral costophrenic angles.
    • 2022-07-19 Patho - stomach subtotal/total
      • pathologic diagnosis
        • Stomach, subtotal gastrectomy — Poorly cohesive carcinoma, signet-ring cell type
        • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
        • Lymph nodes, D2 LN dissection — Negative for malignancy (0/47)
        • Omentum, subtotal gastrectomy — Metastatic carcinoma
        • AJCC Pathologic staging — pT4aN0M1, stage IV
      • microscopic examination
        • Histologic type: Poorly cohesive carcinoma, signet-ring cell type (Lauren classification: diffuse type)
        • Histologic grade: Poorly differentiation (G3)
        • Depth of tumor invasion: Tumor invades the serosa
        • Margins: All margins are uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 2 mm from radial margin
        • Perineural invasion: Present
        • Lymphovascular space invasion: Absent
        • Regional lymph nodes: Negative for malignancy (0/47)
          • 0/7 (LN 1), 0/7 (LN 3), 0/1 (LN 4), 0/3 (LN 5), 0/3 (LN 6), 0/26 (LN 7, 8, 9, 11p, 12a), 0 (LN14v) (Number of LN involved/Number of LN examined)
        • Duodenum: Involved by carcinoma
        • Omentum: Metastatic carcinoma
        • Additional pathologic findings: Reactive gastropathy
        • Pathologic Staging: pT4aN0M1 (stage IV)
        • IHC (S2022-10770): HER2 (negative, score=1+)
        • Ascites Cytology: Negative
    • 2022-07-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (91.5 - 28.5) / 91.5 = 68.85%
        • Normal chamber size
        • Adequate LV and RV systolic function
        • AV sclerosis with trivial AR, trivial MR, TR and PR
        • No regional wall motion abnormalities
    • 2022-07-08 Double contrast upper GI series
      • Findings
        • Normal appearance of the esophagus.
        • There is no evidence of abnormal mucosal pattern at the stomach.
        • Intact EG junction.
        • The gastric angle is intact.
        • Decreased peristasis with poorly opacified gastric pylorous.
      • Imp:
        • Decreased peristasis with poorly opacified gastric pylorous.
    • 2022-07-07 MRI - upper abdomen
      • Suboptimal study due to motion.
      • Hepatic hemangioma. S4/8
      • Enhanced mucosa at gastric pylorous is found. Nature?
    • 2022-07-07 Patho - stomach biopsy
      • Stomach, pyloric ring, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by individual tumor cells infiltratiion. Immunohistochemistry of CK(+) and Her2 (-, Dako score 1+) for tumor. Besides, mild intestinal metaplasia is also noted.
    • 2022-07-06 SONO - abdomen
      • Diagnosis: Hepatic hemangima, right lobe
    • 2022-07-06 Esophagogastroduodenoscopy, EGD
      • Esophagus: Confluent mucosal breaks more than 75% with fagile mucosa and superficial ulcers were noted from EC junctiob to 25cm below the incisors.
      • Stomach: Upon entry, much food debris was noted in stomach. Mucosal swelling was noted at pylori ring, causing pylori stricture that the scope could not pass through. Biopsy *6 was performed the pylori ring.
      • Duodenum: Not checked
      • Diagnosis
        • Incomplete study
        • Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related
        • Pylori stricture, s/p biopsy
      • Suggestion
        • Please pursue pathology report
    • 2022-07-05 CT - abdomen
      • Addendum Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N1(N_value) M:M0(M_value) STAGE:III(Stage_value)
    • 2022-07-05 ECG
      • Normal sinus rhythm
      • ST & T wave abnormality, consider inferior ischemia
      • ST & T wave abnormality, consider anterolateral ischemia
      • Prolonged QT

[consultation]

  • 2022-07-13 General and Gastrointestinal Surgery
    • Q
      • This 69 years old female has the history of hypertension
      • This time, she came to ER for persisit vomit with dizzness in recently 2 weeks, she ver been to LMD but invain. She denied fever or chills, dyspnea or chest pain , abdomen pain, tarry or bloody stool passage recently. She also denied TOCC history.
      • At ER, physical exammination revealed abdomen soft without tenderness and acitve bowel sound. Lab data showed impaird renal function, hyponatremia hypokalemia and the Non-contrast CT of abdomen-pelvis revealed: Bronchiectasis at RML, RLL and LLL. Distention of stomach and dilatation of esophagus. Retroversion of uterus. Initial NG was placed at ER and coffee ground was noted and gastric juice showed OB 3+. KCAL fluid was given to correct hypokalemia. Under the impresion of Vomit, hypokalemia, she was admitted to GI wrd for further management.
      • EGD was perfromed and reported Incomplete study Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related Pylori stricture, s/p biopsy. The pathology reported Poorly cohesive carcinoma with signet-ring cell differentiation. we need your expertise. Thanks~
    • A
      • please arrange heat echo for pre-op survey
      • TPN for nutrition support
      • we will take over for this case
      • further operation will arrange on next week

[surgical operation]

  • 2022-07-18 Radical subtotal gastrectomy and B-II gastrojejunostomy
    • Tumor visible at antrum at lesser curvature of antrum
    • Ring-like tumor about 3cm width at pyloric antrum
    • cT4aN1M0

[chemoimmunotherapy]

  • 2023-02-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 470mg NS 250mL 2hr + fluorouracil 2000mg/m2 2350mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-02 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2000mg/m2 2300mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

    • 2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]

==========

2023-03-15

  • According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.

  • The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.

  • It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.

2023-02-22

  • A low serum magnesium level of 1.6mg/dL (2023-02-21) has been observed, and the patient has been prescribed MgSO4 injections and MgO tablets appropriately.
  • Apart from hypomanesia, the patient’s other laboratory readings were within normal limits, and their vital signs have remained stable throughout this hospitalization.

2023-01-10

  • There has been a frequent low level of magnesium in the patient’s blood for months, this hospital currently has only magnesium oxide tablets available for oral administration, so it is recommended to continue prescribing MgO when he is discharged.
  • MgO should be taken with food and at least 240mL of water (absorption: oral up to 30%). Patients might be educated that whole grains, legumes, and dark-green leafy vegetables are dietary sources of magnesium.

2022-12-09

  • As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.

  • The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.

    • 2022-12-08 Mg (Magnesium) 1.4 mg/dL
    • 2022-11-16 Mg (Magnesium) 1.7 mg/dL
    • 2022-10-17 Mg (Magnesium) 2.0 mg/dL
    • 2022-10-14 Mg (Magnesium) 1.5 mg/dL
    • 2022-10-11 Mg (Magnesium) 1.8 mg/dL
    • 2022-10-03 Mg (Magnesium) 1.8 mg/dL
  • For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.

2022-10-26

  • Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)

  • It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.

  • Vitamin B12 injections might be required, as well as multivitamins and minerals.

  • As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.

2022-09-13

  • Metoclopramide might enhance the CNS depressant effect of lorazepam. The patient should be monitored for signs of increased CNS depressant effects (e.g. somnolence, drowsiness).

700909334

230315

[diagnosis]

  • Malignant neoplasm of overlapping sites of corpus uteri
  • Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV with obstructive Lt lung collapse; ECOG = 3.
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Thalassemia, unspecified
  • Gastrointestinal hemorrhage, unspecified
  • Allergy, unspecified, initial encounter
  • Dysthymic disorder
  • Insomnia due to other mental disorder
  • Constipation, unspecified
  • Chronic viral hepatitis B without delta-agent

[past history]

  • uterus leiomyosarcoma with bone meta, liver and lung metastases s/p OP, pazopanib target therapy with progression and chemotherapy (cisplatin and ifosphamide).
  • Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105~0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110~1224) at Tri-service General Hospital, under current radiation therapy.
  • Gastro-esophageal reflux disease with esophagitis, LA grade D
  • Thalassemia
  • Positive infection of COVID-19 on 2022/05/16

[exam findings]

  • 2023-03-09 CT - brain
    • Clinical information: This 62 y/o female patient has the history of metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • One enhancing nodular lesion (7mm) over right parietal lobe, favor a metastatic lesion.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2023-02-08 CTA - chest
    • Indication: Malignant neoplasm of overlapping site
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
    • Comparison was made with previous CT dated on 2022/12/08
      • Lungs: extensive heterogeneous consolidation with air-bronchograms at left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases.
      • Mediastinum and hila: enlarged LNs in the Rt hilum and intrapulominary LLL.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt effusion extending to major fissure, Rt pleural metastasis and thickening.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • multiple large metastatic hepatic tumors, small metastatic tumors at left kidney and Rt adrenal gland, and a large metastatic tumor at RUQ of abdomial cavity. a large tumor at pelvic cavity involving adjacent organs.
        • small ascites is visible.
    • Impression: Leiomyosarcoma of uterus with multiple sites of metastases, in progression as compared with the previous CT on 2022/12/08
  • 2023-02-08 CXR
    • Extensive heterogeneous consolidation in left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases
    • Port-A catheter inserted into superior RA via left subclavian vein.
    • Diffuse hepatomegaly.
    • Normal heart size.
  • 2023-02-02 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at left lower lung.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-01-25 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Mass like lesion at left upper lobe with nodular lesions at both lungs is found.
  • 2023-01-04
    • A nodular opacity projecting in the left upper lung is suspected. Please correlate with CT.
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • S/P metalic autosuture at left lower lung.
  • 2022-12-13
    • Multiple nodules at bil. lungs.
    • Patch density at LUL.
  • 2022-12-08 CT - chest
    • Indication: Leiomyosarcoma s/p C/T
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Nodular lesions at both lungs up to 3.6cm at right lower lobe is found. In comparison with CT dated on 2021-09-21, the lesion enlarged.
        • Left hilar infiltration is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p ATH and BSO.
        • Soft tissue nodule at right pelvic side wall up to 4.6cm in largest dimension. In progression.
        • Soft tissue mass near uncinate process of the pancreas is found. The lesion enlarged.
        • Low density lesions at both lobes of liver up to 6.4cm in largest dimension is found. In enlargement.
        • The urinary bladder is well distended without soft tissue lesion.
        • Right adrenal enlargment up to 3.09cm is found. In progression. Suggest clinical correlation
    • Imp:
      • s/p ATH and BSO.
      • Residual tumor at pelvis about 4.6cm with liver, lung, right adrenal and uncinate process meta. In progression.
  • 2022-11-15 CXR
    • Progression of left pleural effusion as compare with CXR on 2022-09-21. Suggest clinical correlation.
    • S/P port-A insertion via left subclavian vein.
    • Multiple lung tumors, suspected lung metastasis, progression.
  • 2022-09-21 CT - abdomen
    • History: uterine leiomyosarcoma
      • 20220330 CT from TSGH: a heterogeneous mass 14 cm in the RUQ of abdomen,surround by C-loop of duodenum. Suspected metastasis.
      • 20220524 CC:UGI bleeding, gastroscopy:One 2cm ulcerative mass covering with fresh blood just distal to papilla. Patho:metastatic uterus leiomyosarcoma,
      • 20220623 CT:R/O metastases at pancreatic head and duodenum with duodeno-colon fistula.
    • Indication: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG 2. s/p palliative RT on 2022/06/07.
    • MD CT (64 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • Prior CT identified a metastasis measuring 3.3 cm in S6 of the liver is noted again, mild decreasing in size to 3 cm.
        • However, There are two newly-developed poor enhancing masses measuring 4.3 cm in S4/5/8 and 1.2 cm in S7 of the liver that are c/w newly-developed metastases.
      • Prior CT identified multiple metastases on both lower lung are noted again, mild increasing in size.
      • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
      • S/P hysterectomy.
      • There is mild left pleural effusion.
      • There is a poor enhancing lesion measuring 1.2 cm in left kidney middle pole, nature? Please correlate with sonography.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, spleen & right kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Two newly-developed liver metastases in S4/5/8 and S7.
      • Multiple lung metastases show mild increasing in size.
      • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
  • 2022-09-21, -08-15 CXR
    • Multiple lung tumors, suspected lung metastasis.
    • Regression of left pleural effusion as compare with CXR on 2022-08-15, -07-19.
  • 2022-07-19 CXR
    • Total white-out of left lung and mediastinum shift to left side is noted that may be left lung collapse?
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • There are few nodular opacity projecting in both lung hat may be metastases. Please correlate with CT.
  • 2022-06-28 Abdomen Decubitus LT
    • Left Pleura effusion and left lung volume decrease.
  • 2022-06-28 CXR
    • Left pleural effusion.
    • Deviation of trachea.
    • Multiple nodules at right lung.
  • 2022-06-23 CT - abdomen
    • History and indication: metastatic uterus leiomyosarcoma
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy.
      • Left pleural effusion with adjacent lung collapse. Multiple nodules in right lung.
      • A poor enhancing tumor (3.3cm) at S6 of liver.
      • Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
    • IMP:
      • S/P hysterectomy.
      • Left pleural effusion with adjacent lung collapse. Lung and liver metastases. Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
  • 2022-05-24 Patho - stomach biopsy
    • Duodenum, just distal to papilla, biopsy (A) — Leiomyosarcoma.
    • IHC stains: desmin (+), CD117 (-), CD34 (-), dog-1 (-), CK (-), melan-A (-), Ki-67: 90%.
    • Section shows 1 piece(s) of benign duodenal tissue and 1 piece of neoplastic spindle cell tumor with markedly enlaged and hyperchromatic nuclei.
  • 2022-05-24 Colonoscopy
    • No active bleeder nor blood clot was noted during this exam, but few tarry stool residual was noted
    • Diverticula, cecum and ascending colon
    • Mild internal hemorrhoid
  • 2022-05-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcerative tumor, 2nd portion, s/p biopsy (A)
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric polyps, body, s/p biopsy (B)
      • Gastric erosion, middle body, PW site, s/p biopsy (C)
    • Suggestion
      • Suggest Abdominal CT with contrast (if not contraindicated) to DDx the duodenal lesion.
      • Keep high dose PPI therapy for 3-5 days
      • If acitive bleeding, consider angiography for embolization and surgical intervention. Endoscopic treatment is NOT suitable for such bleeding lesion.
      • Pursue the result of pathology report
  • 2022-04-13 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade D
      • Superficial gastritis
      • Incomplete study
    • Suggestion
      • Consider temporary NG tube for decompression
      • PPI use for severe reflux esophagitis
      • Consider 2nd look endoscopy if active bleeding or persistent tarry stool
  • 2022-04-11 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Rightward axis
    • Pulmonary disease pattern
    • Abnormal ECG
  • 2022-04-11 Abdomen -Standing (Diaphragm)
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2021-03-23 CT (performed at another hospital?)
    • There are several small nodules (maximal size: about 1.7 cm) in all lobes (im:87) showing no change in size in comparison with the prior study obtained on 2020-12-02, lung metastasis is suspected. Suggest get tissue diagnosis
    • Multiple hypodense lesions in the spleen. Suggest correlate with abdomen CT study

[consultation]

  • 2023-01-05 Oral and Maxillofacial Surgery
    • Q
      • This is a 62-year-old female who has the underlying disease of the following below: 1. Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105-0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110-1224) at Tri-service General Hospital, under current radiation therapy. 2. Gastro-esophageal reflux disease with esophagitis, LA grade D 3. Thalassemia 4. Positive infection of COVID-19 on 2022/05/16.
      • For throbbing pain in upper left tooth, we need your further evaluation and management. (throbbing pain consists of recurring achy pains, may also experience pounding, beating, or pulsing pain.)
    • A
      • deep caries of tooth 26 was noticed.
      • But due to unstable hemodynamic status, Hb = 3.1 g/dL, blood transfusion was performed at ward
      • we suggested symtpom relief/pain relief (NSAID if no contraindicated/gastric ulceration)
  • 2022-07-01 Radiation Oncology
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB, patient asks for RT for treamtent.
    • A
      • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis s/p to RUQ tumor from 2022-04-27 to 2022-06-07 with duodeno-tumor fistula and intermittent tumor bleeding; left pleural effusion with adjacent lung collapse, due to tumor obstruction of left main bronchus; ECOG = 2.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: Metastatic tumor at left main bronchus.
          • Technique: VMAT & IGRT (OBI).
          • Dose & Fractionation: 2400cGy/6 fractions.
          • Expected benefits: about 60-70% chance to open the left bronchus, improve breathing, and last for about 1-2 months.
      • Plan: Palliative R/T is suggested for tumor obstruction. Possible toxicity (malaise, radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2022-07-04 15:30pm. Treatment will be started on next Tuesday or Wednesday if feasible.
        • Hospice care is also suggested. It has been recommended that family members be prepared for the best and the worst. Infection, bleeding, and other metastases may pose a threat at any time to the patient. Get to know the wisdom of letting go at the right time and adapt anticipatory grief accordingly.
  • 2022-06-30 Family Medicine
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB and abdomen CT with duodeno-colon fistula, can’t do the surgical intervention. Due to terminal stage, so we need your help for share care. Thank you.
    • A
      • When I visited, the patient lied on bed and her caregiver stood by her. She still wanted to receive palliative radiotherapy. After discussion, I decided to arrange hospice combine care for this patient.
      • Current condition: 62 y/o metastatic uterus leiomyosarcoma
      • Indication for hospice combine care: metastatic uterus leiomyosarcoma
  • 2022-06-28 General and Gastroenterological Surgery
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula. So we need your help for surgical indication management. Thank you.
    • A
      • S: Gastroenterological SurgeryDue to UGI bleeding, surgical intervention is consulted.
      • O:
        • vital signs: stable, no fever
        • HEENT: pale conjunctiva, OU
        • abdomen: soft, ovoid, normal bowel sound, RUQand epigastric tenderness, no rebounding pain
        • lab data: see chart
      • A: uterus leiomyosarcoma with multiple metastases,suspect duodeno-colon fistula and UGI bleeding
      • P:
        • Please arrange panendoscopy and colonoscopy for bleeding source and duodeno-colon fistula and possible hemostasis
        • Please use high dose PPI and keep blood transfusion if onging GI bleeding
        • If UGI bleeding is not well control after medication, blood trasfusion, and GI scope hemostasis, TAE is preferred than operation in stage IV case.
  • 2022-06-27 Gastroenterology
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula and stool ob 4+ with anemia Hb: 6.6d/dL. So we need your help. Thanks!
    • A
      • EGD on 20220524 showed a duodenal ulcerative tumor in 2nd portion, which was compatible with the CT finding
      • But the colonoscopy at the same time did not showed evidence of fistula
      • CT scan (20220623) reported a large tumor located between duodenum and pancreatic head region with suspicious duodeno-colonic fistula. Though, intraperitoneal free air accumulated below liver could not be ruled out.
      • Imp: Duodenal or pancreatic head tumor (suspected metastasis) with duodeno-colonic OR duodeno-peritoneal fistula
      • Suggestion:
        • Consult GS for surgical indication
        • Keep on PPI for the sign of UGI bleeding due to the duodenal tumor
  • 2022-04-25 Radiation Oncology
    • A
      • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG = 3.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: RUQ tumor.
          • Technique: VMAT.
          • Dose & Fractionation: 2500-3000cGy/10-12 fractions.
          • Expected benefit: about 30-40% chance to improve tumor bleeding and obstruction, lasting for about 1-2 months.
      • Plan: Palliative R/T is suggested for tumor obstruction and bleeding. Possible toxicity (malaise, vomiting, radiation gastritis and enteritis) is told. CT simulation is arranged on 20220426 16:00pm. Treatment will be started on Wednesday if feasible.
        • It is recommended that the patient’s spouse and children make an appointment with me to listen to the explanation of the condition and discuss the treatment goals; it is recommended to continue to arrange the hospice ward.

[radiotherapy]

s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).

  • 2023-01-03 ~ 2023-01-19 - 2500cGy/10 fractions (15 MV photon) to duodenal tumor
  • 2022-12-12 ~ 2023-01-02 - 4500cGy/15 fractions (6 MV photon) to LUQ tumors
  • 2022-10-11, -13, -17, -19, -21 - 5000cGy/5 fractions (15 MV photon) to liver tumors over right lobe
  • 2022-08-01 ~ 2022-08-16 - 4200cGy/12 fraction (6 MV photon) to L main bronchus tumor & other 2 tumors
  • 2022-07-05 ~ 2022-07-18 - 2400cGy/6 fractions (6 MV photon) to left main bronchus tumor
  • 2022-04-27 ~ -05-06, -05-15 ~ -06-01, -06,07 - 3000cGy/15 fractions (15MV photon) to RUQ tumor

[immunotherapy]

  • 2023-03-14 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-20 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-01-09 - nivolumab 3mg/kg 100mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2022-12-19 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL

==========

2023-03-15

  • Based on the available data, this patient’s HGB level has consistently remained below the lower limit of normal and requires blood transfusions to prevent it from dropping further.
    • 2023-03-13 HGB 6.4 g/dL
    • 2023-03-08 HGB 7.4 g/dL
    • 2023-03-02 HGB 8.2 g/dL
    • 2023-02-15 HGB 8.0 g/dL
    • 2023-02-08 HGB 9.3 g/dL
    • 2023-02-02 HGB 8.7 g/dL
    • 2023-01-31 HGB 10.1 g/dL
    • 2023-01-25 HGB 7.7 g/dL
    • 2023-01-25 HGB 6.6 g/dL
    • 2023-01-17 HGB 8.5 g/dL
    • 2023-01-09 HGB 8.9 g/dL
    • 2023-01-07 HGB 7.9 g/dL
    • 2023-01-04 HGB 3.1 g/dL
    • 2022-12-18 HGB 10.5 g/dL
    • 2022-12-15 HGB 4.9 g/dL
    • 2022-12-13 HGB 8.8 g/dL
    • 2022-12-07 HGB 6.5 g/dL
    • 2022-11-15 HGB 6.1 g/dL
    • 2022-10-18 HGB 6.4 g/dL
    • 2022-09-20 HGB 7.2 g/dL
    • 2022-08-30 HGB 7.9 g/dL
    • 2022-08-16 HGB 6.9 g/dL
    • 2022-07-19 HGB 11.3 g/dL
    • 2022-07-10 HGB 9.1 g/dL
    • 2022-07-06 HGB 7.1 g/dL
    • 2022-06-28 HGB 8.4 g/dL
    • 2022-06-26 HGB 6.6 g/dL
    • 2022-06-23 HGB 8.9 g/dL
    • 2022-06-21 HGB 8.9 g/dL
    • 2022-06-15 HGB 6.8 g/dL
    • 2022-06-07 HGB 8.8 g/dL
    • 2022-05-30 HGB 10.0 g/dL
    • 2022-05-27 HGB 9.3 g/dL
    • 2022-05-26 HGB 9.4 g/dL
    • 2022-05-25 HGB 5.1 g/dL
    • 2022-05-23 HGB 9.6 g/dL
    • 2022-05-22 HGB 5.8 g/dL
    • 2022-05-21 HGB 9.6 g/dL
    • 2022-05-17 HGB 10.8 g/dL
    • 2022-05-12 HGB 9.4 g/dL
    • 2022-05-05 HGB 8.0 g/dL
    • 2022-04-27 HGB 10.0 g/dL
    • 2022-04-25 HGB 10.3 g/dL
    • 2022-04-24 HGB 8.3 g/dL
    • 2022-04-24 HGB 9.7 g/dL
    • 2022-04-18 HGB 7.9 g/dL
    • 2022-04-14 HGB 8.0 g/dL
    • 2022-04-12 HGB 6.8 g/dL
    • 2022-04-08 HGB 11.4 g/dL
    • 2021-05-04 HGB 10.4 g/dL
    • 2020-09-09 HGB 10.0 g/dL
  • This patient has received nivolumab immunotherapy 5 times since 2022-12-19 and has undergone multiple rounds of radiotherapy between late April 2022 and late January 2023. It is unlikely that anemia can be solely attributed to nivolumab, as hematologic immune-related adverse events from nivolumab occur less frequently and the exact mechanism of anemia is unknown. However, they are typically non-dose-related. The anemia in this patient may also be caused by other factors, such as the multiple rounds of radiotherapy she has undergone.

2023-03-14

  • Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.

    • ref:
      • Immunotherapy with single agent nivolumab for advanced leiomyosarcoma of the uterus: Results of a phase 2 study. Cancer. 2017;123(17):3285-3290. doi:10.1002/cncr.30738
      • Pembrolizumab in advanced soft-tissue sarcoma and bone sarcoma (SARC028): a multicentre, two-cohort, single-arm, open-label, phase 2 trial [published correction appears in Lancet Oncol. 2017 Dec;18(12 ):e711] [published correction appears in Lancet Oncol. 2018 Jan;19(1):e8]. Lancet Oncol. 2017;18(11):1493-1501. doi:10.1016/S1470-2045(17)30624-1
  • Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.

  • There is no medication reconciliation issue found in the patient.

2023-02-21

  • 2023-02-08 CT showed disease progression compared to 2022-12-08 CT.
  • The patient has had a relatively low blood pressure of around 100/70 and a slightly elevated resting heart rate of around 90 during her hospital stay. Adequate hydration may be beneficial in this situation.

2023-02-03

  • Tramectedin is an alkylating agent approved for the treatment of unresectable or metastatic soft tissue sarcomas (liposarcomas or leiomyosarcomas). It is a temporary purchase item in this hospital and could be a subsequent option if nivolumab becomes less effective. For patients previously treated unresectable/metastatic liposarcoma or leiomyosarcoma: IV 1.5 mg/m2 as a continuous infusion over 24 hours once every 3 weeks; continue until disease progression or unacceptable toxicity.
    • ref:
      • Efficacy and Safety of Trabectedin or Dacarbazine for Metastatic Liposarcoma or Leiomyosarcoma After Failure of Conventional Chemotherapy: Results of a Phase III Randomized Multicenter Clinical Trial. J Clin Oncol. 2016;34(8):786-793. doi:10.1200/JCO.2015.62.4734
      • Doxorubicin alone versus doxorubicin with trabectedin followed by trabectedin alone as first-line therapy for metastatic or unresectable leiomyosarcoma (LMS-04): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2022;23(8):1044-1054. doi:10.1016/S1470-2045(22)00380-1
      • The Role of Trabectedin in Soft Tissue Sarcoma. Front Pharmacol. 2022;13:777872. Published 2022 Feb 23. doi:10.3389/fphar.2022.777872

2022-04-15

[tube feeding]

  • All the oral drugs can be administered with a nasogastric tube.
  • The coadministration of fentanyl, diphenhydramine, and estazolam may enhance the CNS depressant effect, please observe for signs of slowed or difficult breathing, and/or sedation.

701388511

230315

{not completed}

{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}

[lab data]

  • PSA
    • 2022-08-08 PSA 8.100 ng/mL
    • 2022-07-15 PSA 7.360 ng/mL

[exam findings]

  • 2022-08-08 Patho - prostate needle biopsy
    • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score = 7 = 4 +3 ) involving 3 of 6 strips of prostatic tissue by the number of involved strips or 50 % by the involved volume of the specimen.
    • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • Histologic Type: Prostatic adenocarcinoma
    • Histologic Grade: Gleason score = 7 = 4 + 3
    • Tumor Quantitation: For needle biopsy: Proportion of prostatic tissue involved by tumor: 3 of 6 strips of prostatic tissue by the number of strips or 50 % by the volume of the specimen.
  • 2022-08-08 Patho - prostate needle biopsy
    • Prostate, left, PSA = 7.360, needle biopsy — stromal and glandular hyperplasia with multiple foci of chronic inflammation. All prostatic glands are 34betaE12 (+) and AMACR (-) with IHC stains.
  • 2022-06-10 SONO - neck
    • Some LNs in bil. neck.
  • 2022-05-12 PET scan (at Cardinal Tien Hospital)
    • Malignant lymphoma with bilateral sides of neck LNs, submental LNs, mediastinal LNs, bilateral axillary LNs, hepatoduodenal ligament LNs, retroperitoneal LNs, bilateral iliac chain LNs and bilateral inguinal LNs involvement.
  • 2022-05-11 Patho - neck (at Cardinal Tien Hospital)
    • high grade lymphoma, favor T-cell lymphoma, angioimmunoblastic T cell lymphoma is compatible.
    • CD3:(+/diffuse), BCL:(+/diffuse), CD20(-), CD10(+), CD4(+), CD21(+) for follicular dendritic cells, CD8(+), EBV(-), MIB-1: highly increasing proliferative index for tumor cells.
  • 2022-05-05 SONO - abdomen (at Cardinal Tien Hospital)
    • fatty liver, hepatic cyst, GB wall thickening, Intra abdominal LN, renal cyst and splenomegaly.
  • 2022-04-28 CT - neck (at Cardinal Tien Hospital)
    • extensive lymphadenopathy at bilateral neck, upper mediastinum on 2022/4/28.
  • Initial presentation
    • body weight loss 10kg in one month and neck lymphadenopathy

[chemoimmunotherapy]

  • 2022-08-14 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-07-25 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-07-04 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-06-10 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5

[family meeting minutes]

  • In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.

  • The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.

701313188

230314

[diagnosis] - 2023-03-13 admission note

  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Localized swelling, mass and lump, neck
  • Chronic sinusitis, unspecified
  • Temporomandibular joint disorder, unspecified

[past history]

Medical history: HTN, Chronic rhinosinusitis

Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration         

[allergy]

  • NKDA     

[family history]

Denied family history

[exam findings]

  • 2023-02-17 SONO - abdomen
    • Liver cysts
    • Gallbladder adenomyomatosis
    • Splenomegaly
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 54) / 131 = 58.78%
      • 2D (M-simpson) = 59
    • Mildly dilated LV with mild hypokinesia of inferior wall, mid-to-apical posterior wall; preserved LV systolic function.
    • Normal RV systolic function.
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Aortic valve sclerosis; midl MR; trivial TR.
    • Mildly dilated aoartic root and proximal ascending aorta (35 mm)
  • 2023-02-14 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
  • 2023-02-10 CXR
    • Solitary pulmonary nodule at RUL.
  • 2023-02-09 Whole body PET scan
    • Glucose hypermetabolism in a left posterior upper neck lymh node and in the right submandibular gland. Lymphoma should be watched out.
    • Glucose hypermetabolism in a focal area in the region about left aspect of soft palate and in the region about right posterior gingiva. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the left parotid and left submandibular areas. Post-operative inflammation may show this picture.
    • Mild glucose hypermetabolism in some bilateral neck level II lymph nodes, in a focal area in the left anterior upper chest and in a focal area in the lower lobe of left lung. Inflammatory process is more likely.
    • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulation may show this picture.
  • 2023-01-27 Patho - salivary gland resection
    • DIAGNOSIS:
      • A: Salivary gland, left parotid, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • B: Salivary gland, left parotid, inferior pole of deep lobe, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • C: Salivary gland, left parotid, superior pole of deep lobe, parotidectomy — Negative for malignancy
      • D: Salivary gland, left parotid, superior margin, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • E: Salivary gland, left submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
      • F: Lymph node, left, level Ib, dissection — Diffuse large B-cell lymphoma, non-GCB type
      • G: Salivary gland, left residual submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
      • F2023-00041
        • Parotid gland, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    • GROSS DESCRIPTION:
      • A: Specimen submitted in formalin consists of a piece of left parotid gland weighing 28.0 gm and measuring 4.7 x 4.7 x 2.5 cm. On cut, there is a gray, solid tumor measuring 4.0 x 3.0 x 1.7 cm. The tumor is involving the anterior, superior, inner resection margins, and 1.2 cm, 0.7 cm, and 0.1 cm away from the posterior, inferior, and outer resection margins. The parenchyma elsewhere is unremarkable. Representative sections are taken and labeled as A1-6: tumor (A1: superior: ink black, outer: ink green, inner: ink yellow; A2: inferior: ink black, outer: ink green, inner: ink yellow; A3: anterior; A4: posterior).
      • B: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 1.8 x 1.0 x 0.3 cm. All for section in a cassette B.
      • C: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.8 x 0.6 x 0.2 cm. All for section in a cassette C.
      • D: Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.4 x 0.8 x 0.6 cm. All for section in a cassette D.
      • E: Specimen submitted in formalin consists of a piece of left submandibular gland tissue measuring 5.0 x 3.0 x 2.4 cm. On cut, there is a gray, solid tumor measuring 3.7 x 3.0 x 2.4 cm. The tumor is involving the peripheral resection margin. Representative sections are taken and labeled as: E1-2: the same level.
      • F: Specimen submitted in formalin consists of 4 level Ib lymph nodes, measuring up to 1.1 x 0.7 x 0.5 cm. All for section in a cassette F.
      • G: Specimen submitted in formalin consists of a piece of left residular submandibular gland tissue measuring 1.8 x 1.4 x 0.6 cm. On cut, there is a gray, solid tumor almost involving the whole specimen. The tumor is involving the peripheral resection margin. The specimen is bisected and all for section in a cassette G.
      • F2023-00041
        • Specimen submitted in fresh consists of a piece of tan, irregular tissue measuring 0.7 x 0.3 x 0.2 cm. All for section in a cassette for frozen examination.
    • MICROSCOPIC DESCRIPTION:
      • A: Sections show salivary gland with diffusely infiltration of large lymphoid cells. The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(-), CD10(-), MUM1(+), Cyclin D1(-), and c-MYC(-). The Ki-67 is about 20-30%. The results are consistent with diffuse large B-cell lymphoma, non-GCB type.
      • B: Section shows salivary gland with infiltration of large lymphoid cells.
      • C: Section shows salivary gland without infiltration of large lymphoid cells.
      • D: Section shows salivary gland with infiltration of large lymphoid cells.
      • E: Sections show salivary gland with diffusely infiltration of large lymphoid cells.
      • F: Section shows 4 lymph nodes with infiltration of large lymphoid cells.
      • G: Section shows salivary gland with diffusely infiltration of large lymphoid cells.
      • F2023-00041
        • Section shows salivary gland with diffusely infiltration of large lymphoid cells and marked crushed artifact.
  • 2022-12-20 CT - neck
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • One well-defined nodular lesion (3.6cm) within left parotid gland, showing homogeneous enhancement. May be a benign mixed tumor. Suggest tissue proof.
      • The oral cavity shows no evidence of focal lesion.
      • The mouth floor and submandibular regions are normal. No focal lesion is identified.
      • Relative hypertrophy of left submandibular gland.
      • The thyroid appears normal in size and enhancement.
      • Effacement of left pyriform sinus.
  • 2022-12-19 Nasopharyngoscopy
    • Findings: synechia between R middle T and septum; bilateral middle T polypoid change with clear to whitish mucus; smooth nasopharynx, oropharynx, hypopharynx.
    • Diagnosis/Conclusion: chronic rhinosinusitis

[chemoimmunotherapy]

  • 2023-03-13 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CDOP)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-02-16 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 20# as 7#, 7#, 6# TID PO D2-6 (R-CDOP)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2

[assessment]

  • The patient’s underlying hypertension is well controlled with Exforge (amlodipine 5mg + valsartan 160mg) currently and there were no medication reconciliation issues.

701328032

230314

[diagnosis] - 20221219 admission note

  • Malignant neoplasm of stomach, unspecified
  • Mixed hyperlipidemia
  • Chronic gastric ulcer without hemorrhage or perforation
  • Ulcer of esophagus without bleeding

[exam findings]

  • 2022-12-22 Body fluid cytology - ascites
    • atypia
  • 2022-12-14 CXR
    • Atherosclerosis of the aorta.
  • 2022-11-14 CXR
    • Ground glass opacity in bilateral lower lungs.
    • Left pleural effusion.
  • 2022-11-11 Patho - gallbladder (benigh lesion)
    • Gallbladder, laparoscopic cholecystectomy — acute cholecystitis, compatible with cholelithiasis
  • 2022-11-11 Patho - stomach biopsy
    • Diagnosis:
      • Stomach, antrum, partial gastrectomy — Poorly differentiated adenocarcinoma
      • Lymph node 1, dissection — Metastatic adenocarcinoma ( 1 / 5 )
      • Lymph node 3, dissection — Metastatic adenocarcinoma ( 2 / 2 )
      • Lymph node 4, dissection — Metastatic adenocarcinoma ( 3 / 7 )
      • Lymph node 5, dissection — Metastatic adenocarcinoma ( 1 / 1 )
      • Lymph node 6, dissection — Metastatic adenocarcinoma ( 3 / 6 )
      • Lymph node, unspecified, dissection — Metastatic adenocarcinoma ( 2 / 7 )
      • Lymph node 14, dissection — Negative for malignancy ( 0 / 1 )
      • Omentum, omentectomy — Negative for malignancy
      • AJCC 8th edition pathology stage:pT4aN3a(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: Partial gastrectomy, distal
      • Tumor Site: Antrum
      • Tumor Size: 5.5x 4.2 cm
      • Gross configuration - For advanced carcinoma (Borrmann classification): Type III: Ulcerated with poorly defined infiltrative margins
      • Sections are taken and labeled as: F2022-530FS:margin, A1:D-margin, A2-12:tumor, B:LN1, C:LN3, D:LN4, E:LN5, F:LN6, G1-2:lymph node, H:LN14, I:omentum
    • Microscopic Description:
      • Histologic Type
        • Adenocarcinoma
        • Lauren classification of adenocarcinoma: Intestinal type
      • Histologic Grade: G3: Poorly differentiated
      • Tumor Extension: Tumor invades the serosa (visceral peritoneum)
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma
        • Distal margin: uninvolved by invasive carcinoma
        • Radial margin: involved by invasive carcinoma
      • Lymphovascular Invasion: present
      • Perineural Invasion: present
      • Regional Lymph Nodes
        • Number of lymph nodes examined/involved: 12 / 29
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT4a: Tumor invades the serosa (visceral peritoneum)
        • Regional Lymph Nodes (pN)
          • pN3a: Metastasis in seven to 15 regional lymph nodes
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
          • Not applicable
      • Additional Pathologic Findings
        • None identified
        • Intestinal metaplasia
      • Ancillary Studies : None
      • Comment(s): None
  • 2022-11-05 CT - chest
    • A nodule at RML. Emphysema at bil. lungs.
    • Gastric antral cancer with outlet obstruction and regional LAP.
    • Left adrenal tumor (1.7cm).
    • Gallbladder stones (up to 1.3cm).
    • A calcified spot (6mm) at right subphrenic region.
  • 2022-11-01 Flow Vlume Test
    • mild obstructive impairment
  • 2022-10-31 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Adenocarcinoma, moderately differentiated
    • The secvtions show a picture of adenocarcinoma, moderately differentiated, composed of cuboidal neoplastic cells, arranged in tubular and papillary patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
  • 2022-10-31 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Advanced gastric cancer with obstruction, Borrmann type III, antrum, s/p biopsy*3
      • Reflux esophagitis LA grade D
      • Incomplete study
    • Suggestion
      • NG decompression
      • Follow up pathology result
  • 2022-10-28 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-10-26 CT - abdomen
    • History: hunger epigastric pain for months, being told to have one huge ulcer at antrum, tissue proved adenocarcinoma (2022-10-04) refer to GS Dr.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the gastric antrum, measuring 1.5 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are five enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N2).
      • There are several gallstones (< 1.5 cm) and mild wall thickening of the gallbladder.
      • There is a calcification 7 mm at S8 of the liver dome that is c/w old granuloma.
      • There is a mass lesion in left adrenal gland, measuring 1.8 cm in size, -2 HU at non-enhanced CT and 42 HU at portal venous phase images.
        • Adenoma of left adrenal gland is highly suspected.
        • Follow up is indicated.
      • Abdominal aorta shows atherosclerosis andectasia 2.2 cm.
      • A renal cyst measuring 0.8 cm in left upper pole is noted. Please correlate with sonography.
      • There is a small soft tissue nodule in RML of the lung, measuring 3 mm in size at lung window setting (Srs:302 Img:7).
        • Follow up chest CT 6 months later is indicated.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2 (N_value) M:M0 (M_value) STAGE:III(Stage_value)

[surgical operation]

  • 2022-11-10
    • Surgery
      • radical subtotal gastrectomy with D2 dissection
      • HIPEC with Oxalip (300mg/M2) at 42 degree C 60 mins
    • Finding
      • distal gastric cancer with multiple LN alpable
      • peritoneal seeding+
      • serosa++

[chemotherapy]

  • 2023-03-13 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2400mg 3880mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-17 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-03 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2000mg 3200mg NS 500mL 46hr + [docetaxel 30mg/m2 20mg + cisplatin 30mg/m2 20mg + gentamicin 20mg + sodium bicarbonate 1400mg] IP 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-10 - oxaliplatin 300mg/m2 510mg IP 1hr (HIPEC)

==========

2023-01-04

Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.

Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.

2022-12-20

  • Cancer multidisciplinary team meeting (2022-12-06) concluded the treatment for the case: arrange further CCRT and keep IP C/T.
  • This patient is admitted for mFOLFOX chemotherapy as arranged. Based on lab data (2022-12-19), the chemotherapy was not contraindicated.
  • There were low levels of albumin (3.1g/dL 2022-12-19) and prealbumin (13.85mg/dL 2022-11-21). They might indicate a short-term impairment in energy intake and the effectiveness of nutritional support.
  • As a diagnosis item, mixed hyperlipidemia is listed, however no associated medication is prescribed, and recent lab data show that triglyceride levels have returned to normal.
    • 2022-11-21 Triglyceride (TG) 109 mg/dL
    • 2022-11-14 Triglyceride (TG) 111 mg/dL
    • 2022-11-08 Triglyceride (TG) 156 mg/dL

700978784

230313

[diagnosis] - 2023-03-12 admission note

  • Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]
  • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
  • Type 2 diabetes mellitus with diabetic nephropathy

[edu opinion] - 2023-03-12 admission note

History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.

Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral

Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.

Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma    

[past history]

  • DM
  • Hyperlipidemia
  • Mucosa‐associated lymphoid tissue (MALT) lymphoma over kidney and urinary system s/p radiotherapy 

[allergy]

  • NKDA

[exam findings]

  • 2023-03-09 2D transthoracic echocardiography

(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.

  • 2023-03-07, 2022-12-20 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
  • 2023-02-21 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, iliac creast, biopsy — Free from lymphoma involvement
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD34 and CD117: positive for blast
      • CD20: positive for B-cell
      • CD3: positive for T-cell
  • 2023-02-17 Patho - colon biopsy
    • Polypoid colonic lesion, cecum, biopsy — Non-specific chronic colitis
  • 2023-02-17 SONO - nephrology
    • Chronic renal parenchymal disease, mild to moderate degree
    • Right renal cysts
  • 2023-01-27 CT - chest
    • Indication:
      • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
      • Type 2 diabetes mellitus with diabetic nephropathy
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Minimal interstitial infiltration over both lungs is found.
        • Patent airway is found.
        • There is no evidence of destructive bone lesion.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Mild left hydronephrosis and hydroureter is found.
        • Right renal stone is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • IMp: Minimal interstitial infiltration over both lungs
  • 2023-01-20 Patho - stomach biopsy
    • Stomach, low body and antrum, biopsy— chronic gastritis with intestinal metaplasia and Helicobacter infection
    • Stomach, cardia, biopsy— inflammatory polyp with Helicobacter infection
  • 2023-01-18 Whole body PET scan
    • Glucose hypermetabolism in the left orbital fossa (Deauville score 5), compatible with lymphoma with tumor recurrence.
    • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes (Deauville score 4-5), tumor recurrence should be considered, suggesting biopsy for further investigation.
    • Glucose hypermetabolism in a lymph node in the right retromolar region (Deauville score 4) and in the gastric region (Deauville score 4), the nature is to be determined (reactive or recurrent nodes, or other nature ?), suggesting follow-up.
    • Increased FDG uptake in the rectal region, the nature is to be determined also, suggesting colon fibroscopy exam. for investigation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • B-cell lymphoma s/p treatment with tumor recurrence, rc-stage II at least, by this F-18 FDG PET scan.
  • 2023-01-02 Patho - soft tissue nontumor/mass/lipoma/debridement
    • PATHOLOGIC DIAGNOSIS
      • Orbital, left, biopsy — Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma, composed of small to medium-sized, slightly irregular nuceli with abundant pale cytoplasm and monocytoid appearance
      • Pathologic Extent of Tumor: To adjacent adipose tissue
      • Additional Pathologic Findings: None identified
      • Immunophenotyping: CD3(-), CD20(+), CD5(-), CD23(focal+), CD43(-), Cyclin D1(-)
  • 2022-12-20 Nasopharyngoscopy
    • polyp over right middle meatus, mucopus over right inferor meatus and left chona, polyp over nasopharynx, fair vocal fold movement
  • 2022-12-14 CT - orbits
    • With and Without contrast CT of the bilateral orbital cavities showed
      • An irregular-margined soft tissue lesion, about 38.7mm, with attachment to the anterior aspect of the left IR muscle. Mild enhancement was noted.
      • The anterior and lateral bony walls of right maxillary sinus were thickened.
      • The mucosal thickening in the bilateral ethmoidal, sphenoidal and right maxillary sinuses with destruction of the medial wall of the right maxillary sinus. Some calcified spots within the right maxillary sinus were noted.
    • IMP:
      • Suspected inflammatory tumor in the left orbital cavity or hemangioma (less likely).
      • Suspected infectious process or tumor in the right maxillary sinus.
  • 2022-12-14 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx, hypopharynx
    • nasal polyp over right middle meatus, no obvious mucopus noticed
    • post-nasal dripping over nasopharynx
  • 2018-10-31 SONO - abdomen
    • Diagnosis
      • Fatty liver,mild to moderate
      • Suspected renal cysts,bil
      • Pancreas not shown
      • Suboptiaml examination of liver due to Poor echo window
    • Suggestion
      • OPD follow up
      • Follow liver function test and AFP
      • Small liver lesion may be masked by bowel gas, especially liver dome

[consultation]

  • 2022-12-14 Ear Nose Throat
    • Q
      • Pain noted around left eye, no blurring of vision
      • Redness +, Swelling +, Local Heat +
      • Past History: DM, HTN
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S
        • Left eye pain and periorbital swelling for 2 months
        • Phx: type 2 DM, dyslipidemia, gout
        • no visual loss, diplopia, facial pain, epistaxis, foul smelling, epistaxis, nasal obstruction, rhinorrhea
      • O
        • Local finding: bilteral pale and boggy inferior turbinates
        • Scope:
          • smooth nasopharynx, oropharynx, hypopharynx
          • nasal polyp over right middle meatus, no obvious mucopus noticed
          • post-nasal dripping over nasopharynx
        • CT: sinusitis over bilateral sphenoid sinus and right maxillary sinus, mass lesion over left infra-orbital region
      • A
        • Impression: Right maxillary sinusitis
      • P
        • Nasonex for right side sinusitis
        • Survey and management of right eye lesion as ophthalmalogist suggested
        • ENT OPD f/u a week later
        • Well education
        • if diplopia, visual loss noticed, back to ER soon
  • 2022-12-14 Ophthalmology
    • Q
      • Pain noted around left eye, no blurring of vision
      • Redness +, Swelling +, Local Heat +
      • Past History: DM, HTN
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S: left periorbital swelling for 1-2 month, no BV, no diplopia, no pain
        • PHx: DM, hyperlipidemia, ophx denied, nka
      • O
        • WBC 6740, CRP 0.8
        • BCVA OD 0.6x-1.75/-2.25x75 OS 0.6x-3.0/-1.0x100
        • PT: 15/18 mmHg
        • pupil: 3mm+/+, 3mm+/+, no rapd
        • palpation : no tenderness
        • Hertel exophthalmometer: 12>–120–<16
        • EOM: mild limitation at lower left gaze os
        • conj: mild chemosis os
        • K: cl ou
        • AC: deep and clear ou
        • LenS: NS + ou
        • F’d: no infiltration, no whitish nor lelvated lesion, no vessel compromise , macula ok, no break ou
      • A: orbital tumor with proptosis, os cause to be determied, lymphoma?
      • P:
        • please consult ENT for sinus lesion
        • explain to the patient, the lesion might be benign or malignant, further survey is needed
        • inform the risk of disesae progression and IOP elevation, if difficulty on opening eye and progressive pain, come back to ER asap
        • opd f/u on W2

[chemoimmunotherapy]

  • 2023-03-13 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
    • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2
  • 2023-02-21 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
    • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2

[assessment]

  • On 2023-03-12, a self-paid G-CSF filgrastin 150ug SC was administered due to leukopenia (WBC count of 2.73K/uL, marked with asterisks in the following table) observed on the same day. The event occurred approximately 3 weeks since the patient’s first R-CHOP treatment started on 2023-02-21. This is longer than the usual 1-2 week timeframe for WBC nadir after chemotherapy. However, it cannot be entirely ruled out that there may be other unidentified factors that are affecting the patient’s WBC count.
    • 2023-03-13 WBC 7.91 x10^3/uL
    • 2023-03-12 WBC 2.73 x10^3/uL *
    • 2023-03-03 WBC 4.72 x10^3/uL
    • 2023-02-19 WBC 3.89 x10^3/uL
    • 2023-02-03 WBC 6.99 x10^3/uL
    • 2023-01-12 WBC 9.84 x10^3/uL

701455299

230310

[exam findings]

  • 2022-12-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 26) / 82 = 68.29%
      • M-mode (Teichholz) = 68.4
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
  • 2022-11-14 Patho - breast simple/partial mastectomy
    • Diagnosis:
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type, grade 2
      • Skin, right breast, partial mastectomy — Negative for malignancy
      • Lymph node, SLN, right axilla, SLNB — Negative for malignancy (0/2)
      • AJCC 8th edition pathology stage:pT1cN0(if cM0); Anatomic stage IA; AJCC prognostic stage IA
    • Gross Description
      • Procedure
        • Partial mastectomy
      • Lymph node sampling (if lymph nodes are present in the specimen)
        • Sentinel lymph node(s)
      • Specimen laterality
        • Right
      • Sections are taken and labeled as:
        • F2022-533FSA1-2: margins,
        • F2022-533FSB: SLN,
        • F2022-533A1-8: tumor and skin,
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma (mm): 15 mm
        • Histologic grade (Nottingham histologic score): grade II (score7)
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ
        • Tumor size (mm): 6 mm
        • Nuclear grade: 2
        • Architectural pattern: Comedo and Non-comedo
        • Tumor necrosis: Present
      • Margins:
        • Negative, Closest margin (7 mm from closest margin)
      • Nodal status: Negative
      • No. examined: 2
      • No. macrometastases (>2 mm): 0
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells):0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast: N/A
        • In the Lymph nodes: N/A
      • Immunohistochemical Study: Reference: S2022-17911
  • 2022-11-11 Frozen Section
    • Margin, right breast, frozen section — Free
    • SLN, axilla, right, frozen section — Negative for malignancy (0/2)
  • 2022-11-11 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2022-10-25 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower T-spine, some L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower T-spine and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-24 CT - chest
    • Indication: Malignant neoplasm of unspecified site of right female breast, Unspecified lump in breast
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images, and oblique coronal reconstructed images of the Rt breast shows:
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
        • Chest wall and visible lower neck: an enhancing nodular lesion with mild lobulated contour (15mm in longest dimension) in inferior central aspect of Rt breast. multiple low density ovalm or round shaped lesions within the breast too measuring up to 3.1cm. no enlarged LNs in axilla.
      • Visible abdominal-pelvic contents: diffuse wal thickening of distal half body and fundal part with sessile luminal nodular lesions of the gall bladder.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, kidneys, uterus, U-bladder, and small and large bowels.
        • no enlarged lymph node. no ascites.
      • Visualized bones: unremarkable.
    • Impression:
      • Rt breast tumor (15mm) and multiple cysts.
      • Gall tumor.
  • 2022-10-17 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • A. Breast, right, nipple, core biopsy — Fibroadenoma
      • B. Breast, right, 6 o’clock, core biopsy — Invasive carcinoma, no special type, NST.
        • IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows fragments of breast tissue with fibroadenoma.
      • B. Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-10-17 SONO - breast
    • Treatment: core needle biopsy
    • Suggestion and Plan:
      • Right breast 6’region tumor, suspected malignancy, suggest biopsy.
      • Right nipple region cystic tumor, suspected intraductal papilloma, suggest biopsy.
      • Multiple bilateral breast cysts.
    • BI-RADS:
      • Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2022-10-17 Mammography
    • Indication: breast lump was noted during regular healthy examination.
    • No previous mammography is available for comparison.
    • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
      • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
      • Multiple oval nodules with obscured margin at bilateral breasts, suggest ultrasound correlation.
      • An irregular mass shadow at right lower central breast, 6’ region, superimposed with microcalcifications and associated with mild architectural distortion. Suggest ultrasound correlation and may consider biopsy.
      • No enlarged axillary lymph nodes.
    • Final assessment:
      • BI-RADS category 0, Need additional imaging evaluation.
      • Suggest ultrasound correlation for bilateral breast masses, especially right 6’ region mass.

[consultation]

  • 2022-11-11 Rehabilitation
    • Q
      • This 43 y.o lady denied systemic disease, op history on contraceptive for 10 years. 5 months before admission, noted solid tumor on 7 o’clock of right breast. Futher investigation was done. Right breast biopsy showed invasive carcinoma no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
        • 2022/10/17 Mamography : BI-RADS category 0, Need additional imaging evaluation.
        • 2022/10/17 Breast sono : 1. Right breast 6’region tumor, r/o malignancy, suggest biopsy. 2. Right nipple region cystic tumor, r/o intraductal papilloma, suggest biopsy.3. Multiple bilateral breast cysts.
        • 2022/10/24 Chest + Abd CT : Rt breast tumor (15mm) and multiple cysts. Gall tumor.
        • 2022/10/25 Bone scan : Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • She is admitted for partial masmectomy + SLND possible ALND.
      • We need your expertse opinion and set up rehabilitation program for post masmectomy and axillary lymph node dissection.
    • A
      • Physical examination
        • 2022/11/10 14:15 T/P/R: 36.5 degree celsius / 66bpm / 17bpm BP:118/56mmHg
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Hand and arm circumference (R/L,cm):
          • Elbow joint above 5cm 23/23.5
          • Elbow joint below 5cm 21/21
      • Imp
        • Breast, right Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
        • Unspecified lump in breast
      • OP: right partial masmectomy + SLND possible ALND on 2022/11/11.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2022-11-11
    • Surgery
      • partial mastectomy and SLNB
    • Finding
      • right 6/1 tumor, about 1.5cm in diameter, frozen: margin free
      • SLNB: negative of malignancy, 0/2
    • Procedure
      • Under ETGA, we harvested the SLNB under gamma-detecter assisted. The frozen section showed negative of malignancy. Then we performed wide excision for right breast tumor. Then frozen section of margin showed negative of malignancy. After one J-vac drain was left, then we closed the wound layer by layers.

[chemotherapy]

  • 2023-02-20 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-03 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-10

  • Currently, there are no observed leukopenia symptoms. However, the time serial data of the WBC count showed a downtrend, with the nadir (marked with an asterisk in the following table) indicating a obvious decrease in accordance with the treatment cycle. To avoid over-suppressing the recovery of WBC, it may be beneficial to consider reducing the dose of epirubicin.
    • 2023-03-08 WBC 7.12 x10^3/uL
    • 2023-03-02 WBC 0.79 x10^3/uL *
    • 2023-02-16 WBC 7.56 x10^3/uL
    • 2023-02-09 WBC 1.13 x10^3/uL *
    • 2023-01-30 WBC 5.90 x10^3/uL
    • 2023-01-12 WBC 2.27 x10^3/uL *
    • 2023-01-03 WBC 5.95 x10^3/uL
    • 2022-12-20 WBC 2.23 x10^3/uL *
    • 2022-12-12 WBC 4.79 x10^3/uL
    • 2022-10-22 WBC 5.16 x10^3/uL

2023-02-20

  • The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.

  • Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate

  • The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.

  • Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.

701443048

230309

[exam findings]

  • 2023-01-09, 2022-12-13, -12-06, -11-22 CXR
    • Increased infiltration over RLL. May be active infection.
    • S/P port-A catheter insertion.
    • S/P tracheostomy.
    • S/P N-G tube insertion.
  • 2022-11-03 Patho - colon biopsy
    • Distal transverse colon, biopsy — Ulcer
  • 2022-11-01 PD-L1 IHC 28-8
    • PD-L1 Immunostaining Result
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percentage of 28-8 expressing tumor cells (%TC): 0%
  • 2022-10-21 MRI - nasopharynx
    • Indication: Malignant neoplasm of tongue, unspecified
    • Findings
      • invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm.
      • enlarged lymph nodes in the bilateral submandibular spaces
      • a nodular lesion about 25mm in the left thyroid gland.
    • IMP: invasive oral cavity cancer, in progression.
  • 2022-10-18 Patho - colon biopsy
    • Large intestine, descending, biopsy —- ulcer with non-specific colitis
  • 2022-10-06 Nasopharyngoscopy
    • Granulation over mouth floor, left gingival sulcus, left tonsillar fossa, tongue base (almost contacted lingual side of epiglottis), bulging of R posterior phayrngeal wall, cystic formation? over R AE fold, fair vocal cord movement
  • 2022-10-05 CT - abdomen
    • History: Recurrent squamous cell carcinoma of tongue, cT4aN0M0, stage IVA
    • Findings:
      • There is distension with fluid and gas collection of the entire colon. please correlate with clinical condition.
      • A renal cyst measuring 1.5 cm in right middle pole is noted.
      • There minimal effusion in right posterior basal CP angle.
  • 2022-10-03 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, suspected buried bumper syndrome
      • Bilious substance in stomach
      • Oral cancer
    • Suggestion
      • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
      • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
  • 2022-09-12 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
  • 2022-08-12 Patho - gingival/oral mucosa biopsy
    • Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma.
    • IHC stains: p16 (-), CK5/6 (+), p40 (+).
  • 2022-08-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed hot areas in the mandible, and increased activity in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints, in whole body survey.
    • IMPRESSION:
      • Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?), suggesting further evaluation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints.
  • 2022-08-09 MRI - nasopharynx
    • Oropharyngeal Cancer (p16-) Staging Form
    • For Oropharyngeal Carcinoma (p16-)
        1. PRIMARY TUMOR:
        • T4 : Moderately advanced or very advanced local disease
          • T4a : Moderately advanced local disease: Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible
        1. REGIONAL LYMPH NODES:
        • N1 : Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE(−)
        1. DISTANT METASTASIS:
        • M0 : No distant metastasis (in this study)
    • AJCC 8th edition Staging status: T4aN1M0
  • 2022-08-08 SONO - abdomen
    • incomplete exam of liver
    • pancreas obscured

[consultation]

  • 2023-03-09 Family Medicine
    • Q
      • For hospice care for pain control and and aromatherapy and lymphatic massage
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022 (The treatment process has been listed in detail in the progress note). ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance and swelling of face were noted. We need your help for combined hospice care for pain control and and aromatherapy and lymphatic massage, Thanks !!
    • A
      • 41 y/o gentleman advanced tongue cancer
      • pain control now
        • Fentanyl 2 large Q3D, Oxynorm (5) 2# q4H, MXL (60) 1# Q12H
      • VAS 5~ 7
      • may add lyrica for neuropathic pain
      • adjust morphine as required
      • Our sahre care would follow up.
  • 2023-03-07 Nephrology
    • Q
      • For severe hyponatremia and unbalance electrolye
      • Because of severe hyponatremia, we need your help, Thanks!!
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was clear, speech was coherent, no respiratory distress, no convulsions and no focal neurological symptoms were noted, and his four limbs were not edematous. He denied having drunk excessive free water or urinated in larger amount than usual.
      • His blood test showed a steep decline in serum Na levels over the course of hospitalization, but we require more data to determine the nature of hyponatremia.
        • 2023-03-06 Na (Sodium) 109 mmol/L
        • 2023-02-27 Na (Sodium) 126 mmol/L
        • 2023-02-24 Na (Sodium) 129 mmol/L
        • 2023-02-20 Na (Sodium) 132 mmol/L
      • Our advices are as follows
        • Adequate hydration with isotonic saline, and avoid 3% hypertonic saline unless patient exhibit severe neurological symptoms
        • Monitor serum Na at least Q12H, changes in serum Na levels should not exceed 4-6mEq/L within 24 hours or osmotic demyelination syndrome (ODS) may develop
        • Monitor urine output amount and neurological symptoms
        • Check serum osmolality, TSH, fT4, ACTH (8am), Cortisol (8am)
        • Check urine osmolality, Na, Cre
      • Please feel free to contact us should you require further assistance.
  • 2023-02-27 Ear, Nose, and Throat
    • Q
      • For nasal bleeding management.
      • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa.
      • MRI revealed tumor had involved to posterior pharyngeal walls. We need your help for nasal bleeding management. Thanks.
    • A
      • S
        • L nasal bleeding even after bosmin gauze compression
        • a case of Recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA with cuffed-tracheostomy (Rota)
      • O
        • Left anterior nasal bleeding
        • trismus and oropharynx invisible, but no blood noticed from oral cavity
        • scope can not be performed due to active bleeding even under bosmin gauze
        • no more bleeding after merocel packing over left common meatus
      • A
        • Left epistaxis
      • P
        • no more bleeding after merocel packing over left common meatus
        • suggest abx usage for merocel insertion
        • may contact us for merocel removal 5-7 days later
  • 2023-02-21 Infectious Disease
    • Q
      • For severe leukocytosis
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022. ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance were noted.
      • Because of severe leukocytosis (CRP:12.19, WBC: 17680) and sputum culture revealed Pseudomonas aeruginosa 2+ and Achromobacter xylosoxidans 2+, we need your help, Thanks !!
  • 2023-01-12 Cardiology
    • Q
      • For severe hypertension
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. Immunotherapy with OPDIVO and CCRT at our hospital since 2022-08-16. ECOG: 3. However, Anemia . hypoalbuminemia and mild electrolyte imbalance were noted . Because of severe hypertension recently, we need your help, Thanks !!
    • A
      • S
        • This 41 y/o male patient is a case of squamaous cell tongue cancer s/p OP and C/T with recurence. He was admitted for palliative chemotherapy. He also had previous history of bronchial asthma and no longer attack in the previous 2 years. High BP was recorded after hospitalization. Now we are consulted for adjusting anti-HTN medications.
      • O
        • BP: 160190/80110+ mmHg, HR:80~110 BPM
        • Current anti-HTN medications: olmetec 1# BID use
        • 20221024 EKG: sinus tachycardia
        • 20230111 BUN/CR:12/0.55, ALT:8, K:3.1
      • Suggestion:
        • Please add adapin (nifedipine 30mg) 1# QD and nebilet (nebivolol 5mg) 1/2 # QD for better BP and HR control.
        • If elevated BP is still recorded 3~5 days later, then push up adapin to 1 # BID, and push up nebilet to 1# QD if no bronchial asthma happens after nebilet treatment.
        • Change olmetec to micardis (telmisartan) 1# QD if above treatment is unsatisfactory for BP control.
  • 2022-11-22 Radiation Oncology
    • Q
      • For radiation therapy
      • This is a 41-year-old male Fillipino patient , he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy and imunotherapy.
        • Anti-neoplastic therapy:
          • Palliative chemotherapy with #3 Erbitux 400mg/M^2 + #2a 90% TPF (Taxotere 36mg/M^2, Cisplatin 36mg/M^2, 5-Fu 900mg/M^2, Leucovorin 90mg/M^2) on 2022/09/07 - 2022/09/09.
          • Palliative chemotherapy with #4 Erbitux 400mg/M^2 + #2b 60% TPF (Taxotere 24mg/M^2, Cisplatin 24mg/M^2, 5-Fu 600mg/M^2, Leucovorin 60mg/M^2) on 2022/09/30 - 2022/10/02.
          • Palliative chemotherapy with #5 Erbitux 250mg/M^2 + #3a 70% Taxotere 28mg/M^2 on 2022/11/01.
          • Palliative chemotherapy with #6 Erbitux 250mg/M^2 + #3b 70% Taxotere 28mg/M^2 on 2022/11/11.
          • Immunotherapy with #1 OPDIVO 160mg on 2022/11/07. 2022/11/22.
    • A
      • S: For palliative radiotherapy due to recurrent left tongue cancer.
      • O
        • PI: This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left oral tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Philippines. Because of recurrent squamous cell carcinoma of tongue, he was admitted for palliative chemotherapy and immunotherapy.
          • Previous RT Hx (2021-11-15 ~ 2021-12-31, St. Luke’s Medical Center, Phippines): 6000cGy/30 fractions of the (GTVp+0.1cm+ entire tongue, base of tongue, alveolar ridge, epiglottis, bilateral retrostyloid, level IB, II, III, IV, V, and modified level VI and left level IA nodes, + margins), 7000cGy/35 fractions of the [(GTVp(heterogenous enhancing mass, left hemitongue extending to the right side) + margin), + prechemotherapy level IIA, bilateral; level IB, right]+ margin] + margin.
        • ECOG: 3
        • PE: oral cavity: protruding tumor mass over anterior tongue border and low gum; poor hearing function; on oxygen inhalation.
        • MRI (2022-08-09): stage T4a(5.3cm, right tongue base; left tonsillar fossa, oropharyngeal wall), N1(right level I, single lymphadenopathy)M0.
        • Bone scan (2022-08-10): Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?)
        • Pathology (S2022-13232, 2022-08-16): Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma. IHC stains: p16 (-), CK5/6 (+), p40 (+).
        • CXR (2022-10-07): No cardiomegaly. No active lung lesion. Normal bony contour. S/P port-A catheter insertion.
        • MRI (2022-10-21): 1. invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm. 2. enlarged lymph nodes in the bilateral submandibular spaces. 3. a nodular lesion about 25mm in the left thyroid gland. Imp: invasive oral cavity cancer, in progression.
      • A:
        • Squamous cell carcinoma of left oral tongue, stage cT3N0M0, stage III, s/p partial glossectomy on 2015/07.
        • Squamous cell carcinoma of left oral tongue, stage cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy and definitive radiotherapy in Philippines, with progression, s/p palliative chemotherapy and immunotherapy.
      • P: Palliative radiotherapy is indicated for this patient with the following indicators: tumor progression
        • Goal: pallaition
        • Treatment target and volume: tumor over left oral tongue to low gum and peripheral involved area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be arranged.
  • 2022-10-28 Thoracic Surgery
    • Q
      • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa. MRI revealed tumor had involved to oropharyngeal walls. However, he had suddened onset severe dyspnea and stridor were found. Acute respiratry failure were highly suspected, we need your for tracheotomy tube insertion. Thanks !!
    • A
      • The patient had buccal ca. s/p CCRT with fibrotic neck
      • Progressive dyspnea noted since last night
      • Tracheostomy may be considered but very high risk of life threatening
      • Consult ANE Dr for evaluation
      • Prepare ICU bed
  • 2022-10-12 Dermatology
    • Q
      • However, patient complained of itching skin lesion suspected fungal infection in right inguinal was noted for a while. We need your expertise and further management. Thanks !!
    • A
      • The patient had sufferred from erythematous to blackwish palques over bilateral inguinal area with staellite active borders.
      • Under the impression of intertrigo eczema with seocndary candidiasis infesation.
      • The following sugeetion:
        • Zalain (sertaconazole) 1 tube topical bid use over large area of invloved area
        • Please keep the affected area dry and clean, add Mycomb (nystatin, triamcinolone, neomycin, gramicidin) 1 tube topical bid use on the active scaling lesions of bilateral inguinal area.
  • 2022-10-03 Gastroenterology
    • Q
      • However, blood stool since 2022-10-02 was noted. Anemia (Hb: 7.9) and tachycardia this morning. Because of suspected GI bleeding. We need your further evaluation and suggestion. Thanks !!
    • A
      • S
        • The 41-year-old man has left tongue cancer, cT3N0M0, stage III, s/p glossectomy and chemotherapy at Philippines. Due to further treatment of recurrent left tongue cancer, he transfered to Taiwan for further management. He just received chemotherapy, finished on 2022-09-30 but bloody stool with tarry was noted. Therefore, we are consulted for further management.
      • O
        • PE
          • conscious: clear
          • chest: smooth breath pattern under room air
          • abdomen: soft and flat
          • extremity: warm
        • Lab
          • Hb: 10.8 -> 7.9
          • Plt: 515k -> 542k
        • 20221003 EGD
          • Diagnosis:
            • Reflux esophagitis LA Classification grade A
            • Superficial gastritis
            • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, r/o buried bumper syndrome
            • Bilious substance in stomach
            • Oral cancer
          • Suggestion:
            • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
            • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
      • Impression
        • Tarry stool with blood clot, lessly like Upper GI tract bleeding by 20221003 EGD, need to rule out Lower GI tract bleeding
      • Suggestion
        • Due to the patient unable oral intake and dysfunction PEG, please use Ducolax 2PC BID + Cleanse enema, then arrange Colonscopy
        • If massive bleeding again or unstable hemodynamic status, please arrange CTA or TAE
        • Due to PEG dysfunction, after bleeding subsided, discuss with GS for further management.
  • 2022-09-28 Infectious Disease
    • Q
      • This 40-year-old male Fillipino patient who sufferred from recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA and under process in palliative chemotherapy treatment. Leukocytopenia, anemia, hypoalbumin and electrolyte imbalance were noted during this chemotherapy course.
      • Current problem: his central line culture showed GNB, we need your further evaluation and suggestion. Thanks !!
    • A
      • S: The patient’s condition was as your description.
      • O: 2022-09-25 B/C: GNB
      • Suggestion:
        • Antibiotics with finibax 500mg iv q8h for GNB sepsis is suggested.
        • DC tapimycin
        • Please remove or exchange the CVP
        • Check CXR
  • 2022-09-07 Metabolism and Endocrinology
    • Q
      • However, his thyroid function showed T3 46.195ng/dl, T4 4.076, free T4 1.388 and TSH 1.3. We need your further evaluation and suggestion. Thanks !!
    • A
      • S
        • This 40-year-old male, with past history of squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino, was admitted due to recurrent squamous cell carcinoma of tongue and for palliative chemotherapy. We were consulted for abnormal TFT.
      • O
        • HR: 119
        • Possible related medication: Thyroxine 50 mcg 1# QDAC for 2 months until now (according to his family)
        • AST/ALT: 50/85
        • BUN/Cr: 13/24
        • Na: 137, K: 3.7
        • TSH/FT4: 1.300/1.388
        • T3: 46.195
        • ATPO, ATG, TSH receptor Ab: unavailable
        • ACTH/Cortisol: unavailable
        • ECG: sinus tachycardia (8/8)
      • A
        • Sick euthyroid syndrome
        • R/I radiation related primary hypothyroidism
      • Suggestions
        • Keep thyroxine 50 mcg 1# QDAC as before
        • Check ATPO, ATG in the next lab
        • Recheck TSH/FT4 2 weeks later or Meta OPD follow, including thyroid ultrasound
        • Contact us if needed. I’d like to follow up this patient.
  • 2022-08-12 Gastroenterology
    • Q
      • However, his Anti-HCV (+) and value showed 1.20 were noted. We need your further evaluation and suggestion. Thanks !!
    • A
      • check Bil(D), a-Fetoprotein, HCV RNA PCR (quantitative)
      • Well explained to the patient low incidence of HCV reactivation during or after chemotherapy according to previous reports
      • GI OPD f/u for treatment

[chemoimmunotherapy]

  • 2023-03-09 - methotrexate 30mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-21 - pembrolizumab 200mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-16 - docetaxel 32mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-09 - docetaxel 32mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-31 - pembrolizumab 200mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-30 - methotrexate 30mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-03 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-28 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-12-20 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-09 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-12-06 - cetuximab 250mg/m2 400mg 1hr + docetaxel 40mg/m2 60mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-24 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-22 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-11-10 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-07 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg 
  • 2022-11-01 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 48mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-09-30 - cetuximab 250mg/m2 400mg 1hr + docetaxel 24mg/m2 40mg in NS 100mL 1hr + cisplatin 24mg/m2 40mg in NS 300mL 3hr + [leucovorin 60mg/m2 100mg + fluorouracil 600mg/m2 1000mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-09-07 - cetuximab 250mg/m2 400mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-23 - cetuximab 250mg/m2 440mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-16 - cetuximab 400mg/m2 700mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2023-03-09

[assessment - appetite stimulant]

  • The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.

  • Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.

    • ref:
      • Cyproheptadine is an effective appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2004;38(2):129-134. doi:10.1002/ppul.20043
      • Long-term trial of cyproheptadine as an appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2005;40(3):251-256. doi:10.1002/ppul.20265
  • Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.

[assessment - pain control]

  • MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.

  • NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.

  • If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.

2023-02-10

  • HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.

  • Platin- and taxel-based treatments have been administered to the patient.

    • Cisplatin-induced neuropathy was more similar to neuropathy in patients receiving oxaliplatin than in those receiving paclitaxel. The cisplatin and oxaliplatin groups exhibited the coasting phenomenon and more prominent upper extremity symptoms than lower extremity symptoms during chemotherapy administration weeks. In contrast, paclitaxel-treated patients did not, on average, exhibit the coasting phenomenon; additionally, lower extremity symptoms were more prominent during the weeks when paclitaxel was administered. ref: Cisplatin-associated neuropathy characteristics compared with those associated with other neurotoxic chemotherapy agents (Alliance A151724) [published correction appears in Support Care Cancer. 2021 Nov;29(11):7129-7130]. Support Care Cancer. 2021;29(2):833-840. https://doi.org/10.1007/s00520-020-05543-5
    • Cisplatin-induced peripheral neuropathy (CIPN) is a frequent serious dose-dependent adverse event that can determine dosage limitations for cancer treatment. CIPN severity correlates with the amount of platinum detected in sensory neurons of the dorsal root ganglia (DRG). After cisplatin-induced DNA damage, p21 appears as the most relevant downstream factor of the DDR in DRG sensory neurons in vivo, which survive in a nonfunctional senescence-like state. ref: Cisplatin-induced peripheral neuropathy is associated with neuronal senescence-like response. Neuro Oncol. 2021;23(1):88-99. https://doi.org/10.1093/neuonc/noaa151
  • 2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399

    • Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813 https://doi.org/10.1001/jama.2013.2813
    • There is Cymbalta (duloxetine 30mg/cap) available in the stock. According to the patient’s lab results of 2023-02-09, his liver and kidney function have not deteriated, so no dose adjustment is required. Cymbalta 1# QD is recommended to mitigate his neuropathy.
  • The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.

    • Compared to TPF (docetaxel, cisplatin, fluorouracil) induction chemotherapy, CT (carboplatin, paclitaxel) induction chemotherapy had at least similar if not better LRC and PFS in patients while having less renal toxicity. Thus, CT induction chemotherapy may benefit patients with locally advanced HNSCC by facilitating adequate chemoradiation regimens that enhanced disease control. ref: Comparison of carboplatin-paclitaxel to docetaxel-cisplatin-5-flurouracil induction chemotherapy followed by concurrent chemoradiation for locally advanced head and neck cancer. Oral Oncol. 2014;50(1):52-58. https://doi.org/10.1016/j.oraloncology.2013.08.007

[duplicate note]

  • As the note has already been responded to, please disregard this duplicate note generated by the system.

2023-01-30

  • Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.

  • Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.

701472893

230309

[exam findings]

  • 2023-03-01 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myeloproliverative neoplasm and see description
    • The sections show normocellular marrow (30%). The M/E ratio about 2:1 in MPO and CD71 immunostains. Increased numbers of small to enlarged CD61+ megakaryocytes with occasional hyperchromatic nuclei, arragned in loose clusters are present. No left shift of myeloid series and erythroid precursors. A few CD34+ and/or CD117+ immature cells in interstitium, account for <3% of nucleated cells can be found. Loose network of reticulin with many intersections (MF-1) in reticulin stain. The finding is compatible with myeloproliferative neoplasm. The differential diagnosis including prefibrotic/early primary myelofibrosis and essential thrombocythemia. Suggest bone marrow smear evaluation, genetic study and clinic correlation.
  • 2023-03-01 CT - brain
    • Indication: Thrombocythemia with dizziness, R/O CVA
    • IMP: No evidence of intracranial lesion.
  • 2023-02-24 CT - abdomen
    • CC: abdominal pain, diarrhea once and vomit > 3 times since last night
      • no fever, headache (+), no family had similar symptom
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple hyperdense lesions in the stomach, duodenum, and small intestine that may be food materials.
        • please correlate with clinical condition.
      • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas. In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
        • Please correlate with GYN. sonography.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas.
      • In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
      • Please correlate with GYN. sonography.

[consultation]

  • 2023-02-08 Ear Nose Throat
    • Q
      • This 43-year-old woman patient is a case of Thrombocythemia with dizziness. Now, for evaluate ear examine of dizziness. Thank you.
    • A
      • S:
        • intermittent Vertigo for 1 month
        • when lying down and getting up from the bed in the morning and at night?
        • Duration: 50 mins
        • First attack: this time
        • Headache(+) for 1 month
        • Tinnitus(-), Hearing loss(-), aural fullness(-)
        • N/V and abdominal pain since last Thursday, improved now nausea or vomiting now, but still intermittent vertigo and headache
        • PHx: denied
        • Allergy: denied
      • O:
        • Ear drums: intact
        • No spontaneous, positional , positioning nystagmus
        • Finger nose finger : ok
        • Romberg test : ok
        • Tandem gait : ok
        • Dix-Hallpike test: Bil negative
        • Supine roll test: Bil negative
      • A: Vertigo, cause?
        • central origin can’t be ruled out
      • P:
        • Please rule out central lesion due to thrombocythemia
        • Brain image study: had arranged
        • Treat thrombocythemia as your expertise
        • may consider diphenidol and nicametate citrate
        • ENT/Neuro OPD f/u

700378861

230306

[exam findings]

  • 2023-03-01 SONO - chest
    • Pleural effusion, minimal, bilatera
    • Consolidation, LLL and RLL
  • 2023-02-27, -02-25, -02-23, -02-20, -02-17 CXR
    • S/P nasogastric tube insertion
    • S/P CVP line insertion from left jugular vein and the tip located at SVC.
    • Atherosclerotic change of aortic arch
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear and nodular infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Borderline cardiomegaly
  • 2023-02-23 KUB
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-22 CT - brain
    • Indication: Myelodysplastic Syndrome
    • IMP: No evidence of intracranial lesion.
  • 2023-02-22 SONO - abdomen
    • GB wall thickening, possibly secondary to hepatitis or ascites
    • Parenchymal renal disease
    • Left renal cyst
    • Ascites
    • Pleural effusion
    • suboptimal echo window
  • 2023-02-17 MRI - L-spine
    • Indication: Myelodysplastic Syndrome. bilateral lower limbs weakness
    • Impression:
      • Degenerative spinal and disc disease.
      • Favor intramuscular hematomas in right psoas muscle.
  • 2023-02-08 SONO - chest
    • Symptoms:
      • Internal jugular vein narrowing or thrombosis.
      • Peripheral vein narrowing
    • Indication:
      • Risky in bleeding, thrombosis, vessel narrowing.
    • Clinical Diagnosis
      • COVID-19 pneumonia with ARDS.
      • MDS with severe pancytopenia
    • Echo Diagnosis
      • Right side
        • Internal jugular vein and common carotid artery confirmed by echo probe compression, Doppler velocity detection.
        • Internal jugular vein compress: lumen narrowing, velocity increasing.
        • Internal jugular vein lumen narrowing and velocity increase during inspiration.
        • Cross-sectional probe: lumen area: 0.66cm in diameter
        • Thrombosis: No
  • 2023-02-02 CT - abdomen
    • History and indication: SOB
    • IMP: Ground glass opacities at bil. lungs. Some LNs at mediastinum. Pericardial and pleural effusion.
  • 2023-01-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • diverticulum : the second portion of duodenum
    • Suggestion
      • PPI therapy
      • OPD follow-up
  • 2021-09-30 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1)
      • MICROSCOPIC EXAMINATION
        • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 amd MPO stains. The megakaryocytes are not remarkable.
        • Slightly increased CD138+ mature plasma cells (5%) in interstitium.
        • Increased CD34+ blasts, account for 9% of marrow cells. Only few CD117+ immuture cells. the finding is compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1). Suggest further bone marrow smear evaluation and clinic correlation.
  • 2019-08-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 37) / 119 = 68.91%
      • LVEF = 69
      • M-mode (Teichholz) = 69
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • No vegetation was found by TTE.
    • Flat IVC, consider hypovolemia.
  • 2019-08-11 CT - abdomen
    • Indication: Suspected liver abscess.
    • Impression:
      • No intraabdominal abscess
      • Left renal cyst
      • Prominent pancreatic tail

[consultation]

  • 2023-02-24 Nephrology
    • Q
      • For Hyernatremia evaluation
      • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 20230202, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
      • The lab showed Hyernatremia, Na (blood): 160 -> 163 -> 171 mmol/L, Na (urine): 32 mmol/L, K (blood): 2.5 -> 3.2 mmol/L, K (urine): 18.8 mmol/L, Osmolality (blood): 340mOsn/kg, Osmolality (urine): 236mOsm/kg, Urine SG: 1.006, U/O: 2807.3+ lossml/day(2023/02/20), 1560ml/day(2023/02/21), so we need your help for Hyernatremia evaluation, thanks a lot!!
    • A
      • Patient seen with history reviewed. We are consulted for hyernatremia.
      • pitting edema 2+
      • Lab
        • 2023-02-22 Na(Urine) 46 mmol/L
        • 2023-02-22 Urine osmolarity 281 mOsm/Kg
        • 2023-02-22 Na (Sodium) 171 mmol/L
        • 2023-02-21 Na (Sodium) 163 mmol/L
        • 2023-02-20 Na (Sodium) 160 mmol/L
        • 2023-02-17 Na (Sodium) 141 mmol/L
        • 2023-02-13 Na (Sodium) 141 mmol/L
        • 2023-02-22 BUN 40 mg/dL
        • 2023-02-20 BUN 32 mg/dL
        • 2023-02-17 BUN 31 mg/dL
        • 2023-02-13 BUN 45 mg/dL
      • U/O
        • 2023-02-20 U/O 2807+loss
        • 2023-02-21 U/O 1560
      • Impression
        • hypernatremia, suspected osmotic diuresis
      • Suggestion
        • estimated free water deficit: 8.5L
        • correct hypernatremia with adequate free water (in diet and IVF), since pleural effusion and pitting edema were noted
        • monitor sodium level closely, sodium level decrease should not exceed 8mmol/L/d
        • record I/O
  • 2023-02-20 Infectious Disease
    • Q
      • For antibiotic evaluation
      • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 2023/02/02, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
      • The lab showed leucopenia, pancytopenia due to MDS, Lenograstim and Tapimycin, Mycamine for blood culture: Candida, sputum culture: PDR-K. oxytoca, so we need your help for antibiotic evaluation, thanks a lot!!
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRR
  • 2023-02-08 Gastroenterology
    • Q
      • After admission, he received ventilator support, empiric antibiotics with Tapimycin and Cravit was prescribed for pneumonia treatment, Decan 6 mg IVD QD (2/2-2/10) and DC Remdisivir due to liver failure. LPRBC and LRP were tranfused for anemia and pancytopenia. We need your expert to evaluate his condition and give us advise with hepatitis. Thank a lot
    • A
      • B (-) C (-)
      • Impression
        • Abnormal liver function test, resolving, r/p sepsis related, r/o shock liver (The liver function test was abnormal but it is improving. This could be related to the recent sepsis the patient had and we need to rule out shock liver.)
      • Plan:
        • Arrange abdominal sonography when transfer to a general ward after isolation
        • Check Anti HAV IgM
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
        • Silymarin 1#~2# TID (The National Health Insurance will reimburse when the levels of GOT and GPT are greater than or equal to twice the normal values.)

[chemotherapy]

  • 2022-05-10 - Vidaza (azacitidine) 230mg SC
  • 2022-01-17 - Vidaza (azacitidine) 260mg SC
  • 2022-01-10 - Vidaza (azacitidine) 260mg SC
  • 2021-12-13 - Vidaza (azacitidine) 260mg SC
  • 2021-12-06 - Vidaza (azacitidine) 260mg SC
  • 2021-11-15 - Vidaza (azacitidine) 260mg SC
  • 2021-11-08 - Vidaza (azacitidine) 260mg SC

[assessment]

  • The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.

    • 2023-03-06 Creatinine 2.37 mg/dL
    • 2023-03-03 Creatinine 1.79 mg/dL
    • 2023-02-27 Creatinine 1.54 mg/dL
    • 2023-03-06 eGFR 29.54
    • 2023-03-03 eGFR 40.84
    • 2023-02-27 eGFR 48.58
  • In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.

  • By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.

700701354

230306

{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}

[lab data]

  • HBsAg 2022-06-04 Reactive, Value 4.62 S/CO
  • Anti-HCV 2022-06-04 Nonreactive, Value 0.10 S/CO
  • Anti-HBc 2022-06-04 Reactive, Value 7.96 S/CO
  • Anti-HBc IgM 2022-06-04 Nonreactive, Value 0.12 S/CO

[exam findings]

  • 2023-02-22 CT - chest
    • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA for esophageal cancer follow-up
    • MDCT (128-detector rows, iCT Philips,was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/11/07
      • Lungs: basal segmental consolidation and volume loss of LLL. long subpleural lines at RLL, may be fibrosis.
        • extensive ground-glass opacity at RML and centrilobular nodular opacities at RUL.
      • Mediastinum and hila: s/p left main bronchial stenting.
        • asymmetric wall thickness with luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 2022/08/08. enlarged subcarinal LNs in visceral space, in progression
        • filling defects in pulmonary arteries (distal main, intrapulmonary lobar and segmental/subsegmentsl branches)
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt-sided effusion.
        • opacification of veins in the chest wall and mediastinum
      • Visible abdominal contents:
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
      • Visualized bones: unremarkable.
    • Impression:
      • proression of esophageal cancer with regional LN metastasus and newly developed pulmonary embolism and LLL consolidation/volume and pleural effusion as compared with CT on 2022/11/07
  • 2023-02-21 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Septal infarct, age undetermined
    • Inferior injury pattern
    • ACUTE MI / STEMI
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 25) / 93 = 73.12%
      • M-mode (Teichholz) = 73
    • Normal LV filling pressure; possibly impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mildly dilated aortic root.
    • Sinus tachycardia.
  • 2023-02-19, -02-02 ECG
    • Sinus tachycardia
  • 2023-01-26 Laryngoscopy
    • Findings
      • left nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, small airway
    • Conclusion
      • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
      • supraglottic swelling
  • 2023-01-20 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Left hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-01-09 Esophagogastroduodenoscopy, EGD; Endoscopic Retrograde CholangioPancreatography, ERCP
    • Findings
      • Supraglottic swelling and posterior hypopharynx ulcer was noted.
      • A stricuture was noted at posterior hypopharynx. The regular EGD scope could not be inserted into esophageal inlet.
      • Using guidewire(Jagwire Revolution 0.025in x450cm) and balloon dilatation with CRE ballooin (15-18 mm, 3 ATM) was performed under fluroscopy.
      • After dilatation, the regular EGD scope still could not be inserted pass through the stricture due to the angulation at the stricture site.
    • Diagnosis
      • Hypopharyngeal stricture, s/p endoscopic balloon dilatation
    • Suggestion
      • Repeat CRE balloon dilatation
  • 2023-01-08 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear fibrosis or discoid atelectasis in LLL of the lung?
  • 2022-12-30 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-12-27 Laryngoscopy
    • Findings
      • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, yellowish sputum accumulation at bi hypopharynx, patent airway but small
    • Conclusion
      • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
      • supraglottic swelling
  • 2022-12-19 SONO - abdomen
    • probable liver parenchymal disease
    • pancreas obscured
    • spleen not seen: obscured?
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal inlet stricture, s/p endoscopic balloon dilatation
    • Suggestion
      • Suboptimal effect of the balloon dilatation was noted in this procedure.
      • Repeat dilatation is indicated.
  • 2022-12-13 Patho - stomach biopsy
    • Stomach, mid-body, PW, biopsy — inflammatory polyp. No H.pylori present
  • 2022-12-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal inlet stricture, suspected cancer stenosis s/p CRE balloon dilatation
      • C/W esophageal cancer, 20cm to 35cm below incisor
      • Gastric polyp, mid-body, PW, s/p biopsy, suspected adenoma
      • Superficial gastritis & hiatus hernia
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • Arrange CRE balloon dilatation again and placement of esophageal stent on 20221219.
  • 2022-12-06 CT - brain
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2022-12-05 Esophagography
    • Esophagography revealed obstruction of cervical esophagus with chocking.
  • 2022-12-01 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
  • 2022-11-29 Laryngoscopy
    • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
  • 2022-11-16, -11-04, -10-19, -09-30 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-11-07 CT - chest
    • residual subsegmental atelectasis at basal segments of LLL.
    • suspect progression of esophageal tumor as compared with CT on 20220808.
  • 2022-11-02 SONO - neck (lymph node)
    • Findings
      • Multiple LNs in left middle and left lower neck, with size up to 0.4cm in length at left.
      • No abnormal fluid collection.
    • Imp
      • Multiple small left neck LNs.
  • 2022-10-24 MRI - larynx
    • Remarkly regressed right hypopharyngeal tumor.
    • Multiple abnormal enlarged lymph nodes in left low neck and supraclavicular fossa were noted, suggest check sonography.
    • Severe artifacts at left upper face,neck and oral cavity was noted, this can mask details.
    • Highly suspected regrowth of upper thoracic esophageal tumor/CA, was noted.
  • 2022-09-22 Laryngoscopy
    • Findings:
      • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, mucus coating on supraglottis and bi hypopharynx, no gross tumor found at hypopharynx
    • Conclusion:
      • hypopharyngeal cancer s/p CCRT, no evidence of tumor recurrence
  • 2022-09-07, -09-02 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-09-05 ECG
    • Sinus tachycardia
    • Rightward axis
    • Borderline ECG
  • 2022-08-25 Laryngoscopy, Stroboscopy
    • hypopharyngeal cancer s/p CCRT
  • 2022-08-08 CT - chest
    • Findings
      • Lungs: residual atelectasis at basal segments of LLL. normal appearance of LUL and Rt lung.
      • Mediastinum and hila: s/p left main bronchial stenting. decrease wall thickness and luminal dilatation of lower third esophagus compared with CT on 20220604. small LNs in visceral space.
      • Pleura: trace Lt-sided effusion or thickening or nodule.
    • Impression:
      • Regression of lower third esophageal tumor as compared with CT on 20220604. LLL basal segmental atelectasis.
  • 2022-08-02, -07-04 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
  • 2022-07-07 Abdomen - standing (diaphargm)
    • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease .
  • 2022-06-23 CXR
    • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
    • post Lt main bronchial stent placement, with expansion of atelectatic left lung
  • 2022-06-15 CXR
    • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • 2022-06-13 CXR
    • regression Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • 2022-06-08 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • 2022-06-08 Bronchoscopy
    • Nasal mucosal lesion, favor mucocele
    • Orolaryngeal wall tumor invasion
    • Endobronchial tumors invasion of whole left main bronchus, combined with severely external compression with LM near-total obstruction.
  • 2022-06-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (30 - 4) / 30 = 86.67%
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve calcificaiton with no AS and AR; mild MR; trivial TR.
    • LV chamber obliteration and flat IVC, consider hypovolemia.
  • 2022-06-04 CT - CTA, chest
    • CTA of chest revealed:
      • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL.
      • S/P jejunostomy.
      • Hyperplasia of left adrenal gland.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL. No evidence of pulmonary embolism.
  • 2022-05-26 Electrocardiogram, EKG
    • Incomplete right bundle branch block
  • 2022-05-25 Nasopharyngoscopy
    • Scope: smooth NPx, oropharynx
    • post. pharyngeal wall ulcerative lesion s/p biopsy, wound healed
    • saliva and mucus pooling, aspiration+
  • 2022-05-05 Patho - larynx biopsy
    • Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma.
    • IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
    • Specimen submitted in formalin consists of 2 piece(s) of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm.
  • 2022-05-02 Miniprobe Endoscopic Ultrasound
    • Diagnosis
      • Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement
      • Gastric polyp, body, PW, s/p biopsy
      • Reflux esophagitis, LA grade A
      • Hiatal hernia
      • Superficial gastritis, body
    • Suggestion
      • suggest consult ENT for biopsy of hypopharynx lesion
      • Pursue pathology report
  • 2022-05-02 Nasopharyngoscopy
    • smooth nasopharynx and oropharynx;
    • small whitish lesion over left pyriform sinus;
    • bulging over right pyriform sinus;
    • posterior hypopharyngeal wall ulcerative lesion;
    • fair vocal cord movement.
  • 2022-04-29 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower C-spine, some T- and L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-04-28 MRI - brain
    • No evidence of brain metastasis.
    • Mild general brain atrophy.
  • 2022-04-28 Abdominal Ultrasonography
    • Diagnosis
      • Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma
      • Suspected calcified spot, left kidney
    • Suggestion
      • Please correlate with other image study for liver lesion
  • 2022-04-19 Whole body PET scan
    • Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered.
    • Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
  • 2022-04-13 Patho - esophageal biopsy
    • Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
    • The specimen submitted consists of multiple small pieces of gray-tan soft tissue, labeled esophagus, 25 to 28 cm, measuring up to 0.2 x 0.1 x 0.1 cm. All for section and labeled S2020-05275 FS.
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
  • 2022-04-09 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at middle to lower third esophagus up to 7.5cm in length is found. Esophageal cancer is considered. In comparison with CT dated on 2021-08-27, the lesion progressed.
        • Small lymph nodes are found at AP window and paratracheal region.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp:
      • Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression.
      • Mediastinal lymphadenopathy
  • 2021-08-30 Patho - esophageal biopsy
    • Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia)
    • The sections show high-grade (severe) dysplasia, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, cellular atypia and atypical mitotic figures. Changes extend to upper-third of the epithelium. Suggest closely follow up.
  • 2021-08-27 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
        • There is no evidence of esophageal wall thickening.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp: no evidence of esophageal wall thickening in the study.
  • 2020-12-29 Patho - esophageal biopsy
    • Esophagus, middle, biopsy — high-grade dysplasia
    • Microscopically, it shows high-grade dysplasia with aacanthosis and dysplastic change of the epithelial cells.
  • 2020-12-29 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade AEsophageal lesion, middle esophagus s/p biopsy (B)
    • Superficial gastritis, antrum
    • Gastric polyp, GC of body s/p biopsy (A)
  • 2019-11-13 CT - mediastinum
    • Comparison: prior CT dated on 2017/11/27
      • Chest
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
        • Normal appearance of visible thoracic aorta, central pulmonary arteries, and cardiac chmabers.
        • No pleural effusion or nodule.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
        • A tiny subupleural nodule at LUL. normal appearance of the LLL and Rt lung.
        • Unremarkable of the chest wall.
      • Visible abdomen
        • Unremarkable of the liver, spleen, pancreas, both kidneys, GB, and adrenal glands.
        • No enlarged LN.
        • No ascites in the abdominal cavity.
      • Visible bones
        • Mild marginal spurs of multiple vertebral bodies.
    • Impression:
      • esophageal cancer,T2N2M0, s/p compeleted CCRT with no obvious recurrent tumor or luminal narrowing based on this CT study.
  • 2018-07-03 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.660 gms/cm2, about 1.5 SD below the peak bone mass (78%) and 0.6 SD below the mean of age-matched people (89%).
    • IMP: osteopenia
  • 2017-11-27 CT - lung/pleura, chest and upper abdomen
    • Findings
      • Chest:
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
        • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
        • No pleural effusion.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
        • Two tiny subupleural nodule at LUL srs5 img10
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys, GB, and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • No ascites in the abdominal cavity.
    • Impression:
      • esophageal cancer, T2N2M0, s/p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.
  • 2017-03-06 CT - lung/pleura, chest and upper abdomen
    • Findings
      • Chest:
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hila.
        • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
        • No pleural effusion.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric jucntion.
        • Two tiny subupleural nodule at LUL
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Impression:
      • esophageal cancer, T2N2M0, s∕p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.

[consultation]

  • 2023-02-21 Cardiology
    • Q
      • This 61-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up.
      • Chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was started on 2022/12/21. C2D1 for Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09. C2D15 chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09.
      • This time, he suffered from intermittent and progressive chest tightness and chest pain for 2 day. He denied fever, chills, abdominal pain, or dysuria. He visited our ER for management. During ER, vital sign showed BP:114/69, PR:122, BT:36.7 degree Celsius, RR:20. Lab data showed negative cardiac enzyme abnomality, but CRP was elevated. CXR showed focal increased density in the right lower lung field. Under the impression of pneumonia, he was admitted for further management.
      • He complatins chest pain, chest tightness, short of breathing, 12 lead EKG: II, III, aVF ST elevate, follow-up right side 12 lead EKG showed acut MI/ STEMI, so we need your help, thanks a lot!!
    • A
      • The patient was examined and hx was reviewed.
      • O
        • nsp chest tightness and chest pain;
          • aggravated productive cough with wheezing+ in recent days;
        • CxR: elevated L’t diaphragm, suspected LLL consolidation;
        • 2D echo showed preserved LV systolic function; no evidence of segmental asynergy.
      • Imp
        • Sinus tachcyardia, possibly due to underlying infection (possibly L’t pneumonia); no evidence of STEMI now.
      • Suggestion
        • Treat L’t pneumonia and bronchospasm firstly.
        • Check thyroid function for tachycardia survey.
  • 2023-01-09 Gastroenterology
    • Q
      • For esophagus balloon dilation
      • This 60-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He was found esphagus relapse and suspicious hypopharyngeal involvement by PES was done on 2022/04/13 and nasopharyngoscopy 2022/05/02.
      • He received 6 courses CCRT with PF from 2022/06/02 ~11/04. Radiotherapy from 2022/05/30~7/27.
      • This time, he was admitted for exam and chemotherapy on 2023/01/08.
      • He under went CRE balloon dilatation again on 2022/12/19 which showed esophageal inlet stricture.
      • Thus we need your expertise for his balloon dilatation at this admission. Thanks a lot!
    • A
      • 60M, A case of 1) Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. 2) Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0. 3) Squamous cell carcinoma of the middle third esophagus. We are consulted for CRE balloon dilatation.
      • S+O:
        • conscious status: clear
        • HEENT: dysphagia, including drinking water
        • chest: smooth breath sound
        • abdomen: soft and flat
        • Lab
          • WBC: 4700
          • Hb: 11
          • Plt: 208
          • AST/ALT: 30/26
          • INR: 1
          • PT: 10.3
        • EGD(2022/12/19):
          • Esophageal inlet stricture, s/p endoscopic balloon dilatation
      • A:
        • Esophageal squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
        • Esophageal inlet stricture
        • quamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.
      • P:
        • We will arrange EGD for endoscopic balloon dilatation evaluation.
  • 2022-12-13 Thoracic Surgery
    • Q
      • He underwent jejunostomy surgery on 2022/05/06 by doctor Hsieh. The patient complaint about redness around Jejunostomy with leakage recently. We need your help for further evaluation. Thank you very much.
    • A
      • Dear Dr. Wan, I will visit the patient and educate about wound care. Thanks for your consultation!!
  • 2022-12-02 Gastroenterology
    • Q
      • The patient was unable to swallow even water. We need your help for further evalution of esophageal stent. Thank you very much.
    • A
      • Image
        • 2022/11/07 - asymmetric wall thickness and luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 8/8. small LNs in visceral space
      • Impression
        • Dysphagia, suspicious obstruction of recurrent esophageal cancer
      • Suggestion
        • Please arrange Esophagography first to evalute the level of esophagus obstruction, then contact us for further management about esophageal stent placement
        • We would arrange EGD for tthis patient.
  • 2022-11-07 Rehabilitation
    • A
      • Assessment
        • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA
        • Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0
        • Carrier of viral hepatitis B
        • constipation
        • Dysphagia due to esophageal tumor progression
      • Plan
        • The patient is not suitable for swallowing training
        • Food and water cannot pass down the esophagus, they will go back retrogradely and cause aspiration or choking
  • 2022-07-08 Dental Clinic
    • Q
      • For dental evaluation and management
      • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy. He was extracting the teeth (14, 27, 28, 38, 45), and he received CCRT with PF. The family request consult dentistry for dental evaluation and management. Thanks a lot.
    • A
      • #11-#13 The dental bridge is loose, it is recommended to use interdental brushes to maintain oral hygiene.
      • A diagnostic certificate issued by an oral and maxillofacial surgery department is required.
    • 2022-06-09 Infectious Disease
      • A
        • Assessment
          • Consultation for Mepem antibiotic
          • 60-year-old esophageal cancer male patient has received recent chemotherapy
          • High fever yesterday afternoon despite Cravit use for left lung pneumonia.
          • Aspiration pneumonia is the first impression.
          • Sputum culture normal flora only.
          • Cravit is replaced by Mepem yesterday evening.
        • Suggestion:
          1. Continue Mepem for one week first.
          1. Check blood culture report, repeat sputum culture.
    • 2022-06-08 Family Medicine
      • Q
        • The patient and family request to combine hospice care (NHI card annoted DNR), so we need your help, thanks a lot!!
      • A
        • 60 y/o gentleman advanced esophageal cancer. admitted for CCRT
        • Our share care would follow up.
    • 2022-05-26 Thoracic Surgery
      • Q
        • This 60 y/o man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up.
        • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA status post jejunostomy and port-A catheter implantation on 2022-05-06.
        • The patient’s jejunostomy was done under your servise on 2022-05-06. This time, he was admitted due to acute epiglottitis. After admission, antibiotic with Cravit was given. The patient suffered from cold sweating and palpitation while G-tube feeding, and some yellowish discharge from jejunostomy for 4-5 days. NPO was told since last night. We request your consultation for further evaluation.
      • A
        • I have visited the patient and educated about care of jejunostomy. Thanks for your consultation!!!
    • 2022-05-10 Oral and Maxillofacial Surgery
      • Q
        • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy.
        • Upper GI panendoscpope showed one lumen-obstructive tumor was noted from 25 to 30 cm and biopsy was done. Pathology revealed moderately differentiated squamous cell carcinoma. He was referred to our CS OPD. PET scan revealed a glucose hypermetabolic lesion involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis.Endoscopic biopsy proved Esophageal squamous cell carcinoma at middle/lower third esophagus. However, his EUS showed Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement.
        • We consult ENT Dr. Lan for hypopharynx lesion, nasopharngoscopy biopsy show squamous cell carcinoma.
        • After admission, we arranged WBBS, brain MRI, abd. sono, EUS and bronchoscope, for cancer work-up. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. We kept nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently. We also consulted ONCO and for further manegement.
        • Impression: upper to middle esophagus squamous cell carcinoma,cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma.
        • We need to consult you for for pre-RT dental evaluation and management.
      • A
        • This is a 60-year-old man suffered from upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. We were consulted for Pre-radiotherapy dental evaulation
        • O:
          • Hopeless teeth of tooth 14, 27, 28, 38, 45
          • Poor oral hygiene with full mouth gingivitis.
        • P:
          • Explain the finding to patient and his son.
          • Please prescribed Cefa 1g IV Q8H for prophhylaxis.
          • We were arranged further extraction for him .
          • OPD follow up.
    • 2022-05-09 Radiation Oncology
      • The patient’s history was reviewed and patient was examined.
      • S:
        • For radiotherapy due to recurrent esophageal carcinoma and hypopharyngeal carcinoma.
        • PI: The patient was a case of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He suffered from progressive dysphagia since 2021 with body weight loss of 8 kg in 1 month. After a series of work-up, the impression was upper to middle esophageal squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. Nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently.
        • Family history: (father: esophageal cancer).
        • Cancer site specific factors: Alcohol (quit); Smoking (quit); Betel nut (quit).
        • Personal Hx: DM(-); HTN(-); HBV(+)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: neg.
        • Pathology (2013-02-01; S2013-01656): Esophagus, esophagocardiac junction to 32 cm below incisor, biopsy — squamous cell carcinoma.
        • Esophagography (2013-02-22): lower esophageal cancer.
        • CXR (2013-02-18): neg.
        • Chest CT (2013-02-08): Soft tissue mass at lower third esophagus near EG junction up to 5*3.55cm with central necrotic part is found. There is no evidence of mediastinal LAP, however, some lymph nodes (3-4) around EG junction is noted. Esophageal cancer at lower third esophagus. T2N2M0 in the study. Stage IIIa.
        • PET scan (2013-02-20): Glucose hypermetabolism lesion in the esophagus, L/3, probably primary esophagus malignancy; hypermetabolism lesion in the right subcarinal region of mediastinum, probably reactive node or malignancy with lymph nodes metastasis. Staging: TxNxM0.
        • RT (2013-3-11 ~ 2013-4-15): 4500cGy/25fractions of the low third esophageal tumor to peripheral lymphatic area.
        • CT scan of mediastinum (2013-07): resolution of intraluminal mass in lower third of esophagus; post treatment change involving M/3 esophagus?
        • Pathology (S2021-11415, 2021-08-31): Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia).
        • CT scan of lung (2022-04-09): Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression. Mediastinal lymphadenopathy.
        • UGI pandendoscopy (2022-04-13): One lumen-obstructin tumor was noted from 25 to 30 cm, s/p biopsy*8 (A). Lugol solution was applied. Area of sliver color sign was noted at 23-25cm. Biopsy was done. (A). One depressed lesion with loss of vasculature was noted at hypopharynx. Diagnosis: Esophageal cancer, s/p biopsy (A) + (B). Hypopharynx lesion, suspected metastatic lesion
        • Pathology (S2022-06234, 2022-04-14): Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
        • PET (2022-04-19): 1. Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. 2. Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). 3. Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered. 4. Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
        • CXR (2022-04-27): a focal Rt-sided convexity of the azygoesophageal recess interface, raise suspicious of esophageal tumor. Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch. Clean lung fields based on plain image. Normal shape and size of heart. Marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis. Normal appearance of both hila
        • MRI of brain (2022-04-28): No evidence of brain metastasis. Mild general brain atrophy.
        • Abd sono (2022-04-28): Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma. Suspected calcified spot, left kidney.
        • Bone scan (2022-04-29): no evidence of bone metastasis.
        • Miniprobe EUS for UGI (2022-05-02): 1. Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement. 2. Gastric polyp, body, PW, s/p biopsy. 3. Reflux esophagitis, LA grade A. 4. Hiatal hernia. 5. Superficial gastritis, body.
        • Operation (2022-5-6): Feeding jejunostomy + port A
        • Pathology (S2022-07892, 2022-5-9): Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
      • A:
        • Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
        • Squamous cell carcinoma of the hypopharynx, p16 (+).
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: recurrent esophageal carcinoma and hypopharyngeal carcinoma.
        • Goal: curative (if double primary), or palliation (if metastatic chypopharyngeal carcinoma).
        • Treatment target and volume: hypopharyngeal tumor, bilateral neck, to recurrent esopharyngeal tumor area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: probably 5000cGy/25 fractions of the esophageal tumor, bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor to involved neck nodal lesions (if hypopharyngeal carcinoma is 2nd primary).
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 10:30, 2022-05-11.
        • Please consult Dental department for pre-RT dental evaluation and management.
    • 2022-05-05 Hemato-Oncology
      • Impression:
        • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA
        • Hypopharynx tumor suspect SCC s/p biopsy, pending pathology
      • Suggestion
        • For recurrent esophagus cancer, SCC, systemic therapy is indicated (such as 5-FU/capecitabine + oxaliplatin[self-paid]/cisplatin) or clinical trial if available
        • Schedueled feeding jejunostomy + port-A had arranged
      • Thanks for your consultation. We will discuss with patient. If there is any problem, please feel free to let us known
    • 2022-05-02 ENT
      • A
        • Local finding: fair oral cavity and oropharynx
        • Scope: smooth nasopharynx and oropharynx; small whitish lesion over left pyriform sinus; bulging over right pyriform sinus; posterior hypopharyngeal wall ulcerative lesion; fair vocal cord movement.
        • Impression: hypopharyngeal malignancy cannot be ruled out
        • Plan: Biopsy for tissue proof may be required.

[surgical operation]

  • 2022-10-26 Removed port-A and insert new one. Revision of jejunostomy.
  • 2022-06-13 Tracheal stent inseriton.
  • 2022-05-06 Feeding jejunostomy

[radiotherapy]

  • 2022-05-30 ~ 2022-07-27 - 5000cGy/25 fractions (15MV and 6MV photon) of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the reduced hypopharyngeal tumor to bilateral involved neck nodal area.

[chemoimmunotherapy]

  • 2023-02-02 - docetaxel 40mg/m2 65mg NS 200mL 1hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 2hr + fluorouracil 1000mg/m2 1735mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 65mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2023-01-09 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-12-20 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-12-01 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-11-04 - cisplatin 75mg/m2 130mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-09-30 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-09-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-08-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-07-04 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-06-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)

[note]

  • Esophageal and Esophagogastric Junction Cancers NCCN guidelines version 4.2022, 20220907
    • DEFINITIVE CHEMORADIATION (NON-SURGICAL) p51
      • Fluorouracil and cisplatin
        • Cisplatin 75-100 mg/m2 IV on Day 1
        • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4
        • Cycled every 28 days for 2 cycles with radiation followed by 2 cycles without radiation
      • ref: Minsky BD, Pajak TF, Ginsberg RJ, et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combinedmodality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol 2002;20:1167
    • PERIOPERATIVE CHEMOTHERAPY (Only for adenocarcinoma of the thoracic esophagus or EGJ) p50
      • Fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) - (4 cycles preoperative and 4 cycles postoperative)
        • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
        • Leucovorin 200 mg/m2 IV on Day 1
        • Oxaliplatin 85 mg/m2 IV on Day 1
        • Docetaxel 50 mg/m2 IV on Day 1
        • Cycled every 14 days
      • ref: Al-Batran S-E, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastrooesophageal junction adenocarcinoma (FLOG4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-1957.
  • Concurrent Chemoradiotherapy with Docetaxel, Cisplatin, and 5-fluorouracil Improves Survival of Patients with Advanced Esophageal Cancer Compared with Conventional Concurrent Chemoradiotherapy with Cisplatin and 5-fluorouracil. J Cancer. 2018;9(16):2765-2772. Published 2018 Jul 16. doi:10.7150/jca.23456
    • All patients underwent chemotherapy and radiotherapy concurrently.
    • In the CF-RT group, cisplatin (70 mg/m2) was administered via intravenous drip infusion on day 1, and 5-FU (700 mg/m2) via continuous intravenous drip infusion on days 1-5.
    • In the DCF-RT group, docetaxel and cisplatin (both 50 mg/m2) were administered via intravenous drip infusion on day 1, and 5-FU (500 mg/m2) via continuous intravenous drip infusion on days 1-5.
    • Patients underwent 2 cycles of chemotherapy during radiotherapy when no deterioration in overall health or occurrence of adverse events was verified.
    • Patients with severe neutropenia were immediately administered granulocyte-colony stimulating factor (G-CSF).

==========

2023-03-06

  • 2023-03-05 lab data CRP 5.25mg/dL.

  • 2023-03-05 sputum gram’s stain result showed:

    • G(+) Cocci 3+: There is a high amount of gram-positive cocci bacteria present in the sample being analyzed.
    • GNB 3+: There is a high amount of gram-negative bacilli bacteria present in the sample being analyzed.
    • Neutrophil/LPF <10 and/or Epithelial cell/LPF >25: This may indicate that the sample was not collected properly and that there is a risk of contamination.
  • As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.

  • Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.

2023-02-02

  • Lab data on 2023-02-01 were grossly normal. There is no problem with the active prescription, except for the anticipated less effective use of Boren-C by tube-feeding.

2023-01-09

[tube feeding]

  • Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.

  • Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176

  • There are no other drugs in the inventory that contain bromelain.

2022-12-19

  • It has been arranged on 20221219 for a CRE (controlled radial expansion) balloon dilatation and placement of an esophageal stent due to obstruction of cervical esophagus.
  • Medication is sometimes responsible for clogged feeding tubes. To prevent clogs and other related issues, there are general tips for giving medication through a feeding tube:
    • Administer each medication separately.
    • Stop the feeding and flush the tube with water before and after medication administration.
    • Crush only those medications which are immediate-release. Sustained-release and enteric-coated medications don’t dissolve well and may not absorb properly when crushed.
    • Use liquid medications when available.
    • Dilute liquid medications to prevent clogging and gastrointestinal upset, like diarrhea.

2022-12-12

[tube feeding]

  • Except for Broen-C, all oral medications in the active prescription can be administered by nasogastric tube.
  • In order to prevent the bromelain enzyme from being destroyed by gastric juice, Broen-C (bromelain + L-cysteine) is designed as an enteric-coated tablet.

2022-12-02

  • As a result of the CT result obtained on 2022-11-07, it appears that the esophageal tumor has progressed. It was then decided to change the regimen from [cisplatin + fluorouracil] to [docetaxel + leucovorin + fluorouracil + cisplatin], which was initiated during this hospitalization.
  • Neither a non-trivial adverse reaction nor an issue with the active prescription have been observed.

2022-12-01

[tube feeding]

  • With the exception of Boren-C, all other drugs in the active prescription can be administered via nasogastric tube.
  • As an enteric-coated tablet, Boren-C is designed to prevent gastric acids from destroying its key ingredient, bromelain enzyme.

2022-10-03

  • The underlying condition HBV is currently being managed with Vemlidy (tenovofir) without any problems.

2022-09-30

[tube feeding]

  • Broen-C (bromelain + L-cysteine) is an enteric coated tablet that should not be administered through a nasogastric tube. Right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

2022-09-05

[tube feeding]

  • As Harnalidge (tamsulosin 0.4mg PO QDAC) is not intended for use with nasogastric tubes, it is recommended to replace it with Urief (silodosin 8mg PO QD).
  • Broen-C (bromelain + L-cysteine) is formulated as an enteric coated tablet and is not intended for nasogastric tube feeding. Currently, there is no single ingredient bromelain item available in inventory, however, Actein (acetylcysteine 200mg/pk) is available and could partially serve as cysteine.

2022-06-06

  • Initially diagnosed in 2013, this patient now suffers from recurrent esophageal squamous cell carcinoma of cT3N3M0 stage IVA. He has begun receiving CCRT since late May 2022.
  • Additionally, the patient carries viral hepatitis B, which is treated with Vemlidy (tenofovir alafenamide) 25mg PO QDCC.

700081806

230303

[exam findings]

  • 2023-02-27 Patho - gingival/oral mucosa biopsy
    • Bone, chin, removal — Osteitis and osteonecrosis
  • 2022-09-20 MRI - nasopharynx
    • Indication: Recurrence SCC of mandibular gingiva
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • Pulse sequences:1. Precontrast: sagittal and axial, coronal T1WI, coronal T2WI images, axial T2WI 2. Post contrast: axial, coronal T1WI. Slice thickness: 3-5 mm
    • Comparison: 2022/05/13 MRI
      • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect at left mandible, bucco-gingival region.
      • No evident abnormal enlarged lymph node in the visible neck.
      • No obvious abnormal enhancement after contrast medium administration.
      • No obvious gingival nodule or mass was found, though early shallow lesion is hard to be defined on this study.
  • 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • Tissue blocks/unstained slides received labeled as: S2022-15310
    • TC >= 1% and < 5%
    • Percentage of PD-L1 expressing tumor cells (%TC): 1%
  • 2022-09-12 Patho - soft tissue biopsy / simple excision (non lipoma)
    • Skin lesion, chin, frozen and excision — Squamous cell carcinoma, moderately differentiated
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by solid tumor nests show enlarged, pleomorphic nuclei infiltrate in the stroma with keratin formation.
  • 2022-09-09 CT - facial bone
    • Indication
      • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
      • SCC of left lower gingival (T1N0M0 stage I) s/p OP with tongue flap .
      • SCC of lower lower gingival (T4N0M0 stage IV) s/p OP with fibula flap reconstruction
      • During CCRT
      • The STSG wound of left fibula region was healing in progress .
      • Multiple ulceration of left floor of the mouth
      • A little swelling of chin region .
    • Protocol: 2.5mm slice thickness, axial scan and coronal/ sagittal reconstruction
    • Without contrast fical bone CT showed
      • The neck airway was unremarkable.
      • Suspicious a break at the metallic plate of the left posterior mandible.
      • Post-operation change at left buccal region, mandile and maxilla.
      • No neck LAP
    • IMp: suspicious a break at the metallic plate of the left posterior mandible.
  • 2022-07-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • Tissue blocks/unstained slides received labeled as: S2022-09325A1
    • Tumor cell (TC) staining assessment: TC < 1%
  • 2022-06-09 Patho - oral cancer (wide excision without lymph node)
    • PATHOLOGIC DIAGNOSIS
      • Mandibular gingiva, left, wide excision — Squamous cell carcinoma
      • Lymph nodes, llevel 3, right, LN dissection — Negative for malignancy (0/1)
      • Bone, mandible, segmental mandibulectomy — Involved by carcinoma and free margin
      • Pathology stage: rpT4aN0(cM0); Stage IVA
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Wide excision + segmental mandibulectomy + LN dissection
      • Specimen Type:
        • Main location: Left mandibular gingiva
        • Lymph node dissection: Yes, right level III
      • Specimen Integrity: intact
      • Specimen Size: 7.2 x 4.2 x 3.5 cm with skin 3.9 x 3.2 cm, mandible bone, 7.2 cm in length, and three teeth
      • Tumor Site: Mandibular gingiva; Laterality: Left
      • Tumor Focality: Single focus
      • Tumor Size: 2.0 x 1.0 x 0.8 cm
        • Depth of Invasion: 8 mm
      • Mucosal Surface : Ulcerated
      • Gross Tumor Extension: Tumor invades bone
      • Representative parts are taken for section and labeled: A1= tumor + anterior margin of mouth floor, A2= tumor + upper lip, A3= tumor + mouth floor, A4= tumor + buccal mucosa, A5= tumor + skin, A6= lower lip, A7= posterior area of molar, A8= mandible bone. B= level 3 lymph node. F2022-00263 FSA= mouth floor, left, FSB= mouth floor, right
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (moderate differentiated)
      • Microscopic Tumor Extension: To mandible bone
      • Margins: Margins free, Distance from closest margin: 0.5 cm (anterior margin of mouth floor)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes: Negative (0/1)
        • Number of LN examined: 1 (right level 3)
        • Number of LN metastasis: 0
      • Mandibule bone margin: Free of tumor
      • Surgical margins received for frozen section, including mouth floor, right and mouth floor left: Free of tumor
  • 2022-05-13 MRI - nasopharynx
    • Indication:
      • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
      • SCC of left lower gingival s/p OP with tongue flap .
      • A ganuloma like mass was noted of left commisure region with bleeding tendancy s/p CO2 laser surgery on 2022/04/25. Pathology report: SCC
    • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
      • postoperative change at left buccal region, left neck, and left submandibular space.
      • ill-defined enhancing mass lesion (largest diameter about 3.3cm) at left lower gingiva and oral commisure, with invasion to mandibular bone causing cortex destruction and bone marrow signal change, and probably also invasion to left inferior alvealar nerve. T4a disease is compatible.
      • no enlarged cervical lymphadenopathy.
    • Impression:
      • Recurrent left lower gingival cancer, image staging favor T4aN0.
      • Postoperative change at left buccal region and left neck.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4a(T_value) N:0(N_value) M:____(M_value) STAGE:IVA(Stage_value)
  • 2022-05-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the midline lower frontal area of the skull and increased activity in the mandible, sacrum, bilateral shoulders and right sternoclavicular junction in whole body survey.
    • IMPRESSION:
      • Increased activity in the mandible. The nature is to be determined (dental problem? malignancy with local bone invasion?). Please correlate with other clinical findings for further evaluation.
      • Mildly increased activity in the sacrum. Degenerative change may show this picture.
      • A faint hot spot in the midline lower frontal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and right sternoclavicular junction, compatible with benign joint lesions.
  • 2022-04-25 Patho - gingival / oral mucosa biopsy
    • Oral cavity, left lower gingival, incisional biopsy — moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of non-keratinizing tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • Immunohistochemical stain reveals p16(-).
  • 2021-11-15 Patho - gingival/oral mucosa biopsy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left lower gingiva, wide excision — Squamous cell carcinoma
      • Resection margins, ditto — Tumor present at one of peripheral margins
      • Lymph node — N/A
      • AJCC Pathologic staging — pT1, if cN0 and cM0, stage I
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: left lower gingiva
        • Other part(s) included: N/A
        • Lymph node dissection: NO
      • Specimen Integrity: Intact
      • Specimen Size: 1.0 x 0.7 x 0.4 cm
      • Tumor Site: left gingiva
      • Tumor Focality : solitary
      • Tumor Size: 0.4 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 0.1 cm
      • Mucosal Surface: ulcerative tumor
      • Gross Tumor Extension (specify) : can not be assessed
    • MICROSCOPIC EXAMINATION
      • Histologic Type: squamous cell carcinoma
      • Histologic Grade: G2, moderately differentiated
      • Microscopic Tumor Extension: 0.1 cm
      • Margins: tumor present at one of peripheral margins , < 0.1 cm from base
      • Lymph-Vascular Space Invasion: absent
      • Perineural Invasion: absent
      • Neck Lymph Nodes: N/A
      • Immunohistochemistry: CK5/6(+), P63(+), P53(+) and P16(-) for tumor
  • 2021-11-12 MRI - nasopharynx
    • History:
      • Squamous cell carcinoma of left buccal mucosa ,pT1N0M0 post of operation (2012)
      • Squamous cell carcinoma of left upper gingiva, pT1N0(cM0) post of operation (2017)
      • A verrucous like mass was noted of left lower gingival about 0.5 cm in diameter. Pathological report: Squamous cell carcinoma in situ at least.
    • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
      • postoperative change at left buccal region, left neck, and left submandibular space.
      • the primary lesion at left lower gingiva is not obviously seen in this image study. No mandibular bone invasion is noted.
      • no enlarged cervical lymphadenopathy.
    • Impression:
      • Left lower gingival cancer, image staging favor T1N0.
      • Postoperative change at left buccal region and left neck.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T1(T_value) N:0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2021-11-04 Patho - gingival/oral mucosa biopsy
    • Gingiva, left lower, incisional biopsy — Squamous cell carcinoma in situ at least
    • The sections show squamous cell carcinoma in situ at least, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, keratin pearls, marked cellular atypia and atypical mitotic figures. Changes involving the whole thickness of the epithelium. No stromal component can be found, and squamous cell carcinoma can not be excluded. Suggest excision.
  • 2021-04-24 MRI - nasopharynx
    • Indication: SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I). follow up.
    • IMP: C/W left buccal cancer s/p operation without recurrence. Stationary as compared with MRI on 20190907.
  • 2021-04-06 Patho - fissure/fistula
    • Anus, fistulotomy and hemorrhoidectomy — hemorrhoid and consistent with anal fistula
  • 2020-04-07 Whole body PET scan
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2019-09-07 MRI - nasopharynx
    • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20190126.
  • 2019-01-26 MRI - nasopharynx
    • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20180629.
  • 2018-06-29 MRI - nasopharynx
    • bilateral neck LNs, stationary.
  • 2017-12-20 MRI - nasopharynx
    • prominent buccal mucosa in the right inferior buccal region. Nature? bilateral neck LNs, stationary.
  • 2017-08-09 MRI - nasopharynx
    • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
  • 2017-05-04 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Gingiva, upper, left, wide excision — Squamous cell carcinoma
      • Lymph nodes, level V, left neck, dissection — No metastatic carcinoma (0/3)
      • Pathology stage: pT1N0(cMx)
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Wide excision + neck dissection
      • Specimen Type:
        • Main location: Left upper gingiva
        • Other part(s) included: Bone of left maxilla
        • Lymph node dissection: Yes (specify): Left neck level V
      • Specimen Integrity: Intact
      • Specimen Size: 3.5 x 2.4 x 2.0 cm
        • Additional dimensions (maxilla bone): 3.0 x 1.5 x 1.0 cm
      • Tumor Site: Left upper gingiva
      • Tumor Focality: Single focus
      • Tumor Size: Greatest dimension: 0.5 cm
        • Additional dimensions (if available): 0.5 x 0.3 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 3 mm
      • Mucosal Surface: Intact
      • Gross Tumor Extension: To subepithelial connective tissue
      • Representative parts are taken for section and labeled as: A1= anterior palatal, A2= palatal gingiva, A3= posterior buccal, A4= superior buccal, A5= anterior buccal, A6= bone, B= level V LN, C= left maxilla bone.
      • The specimen received for frozen section consists of four pieces of gray red soft tissue, labeled cheek mucosa, maxillary site, anterior margin, posterior margin; measuring 0.6 x 0.4 x 0.3 cm, 0.7 x 0.5 x 0.4 cm, 0.4 x 0.3 x 0.2 cm, 0.5 x 0.3 x 0.2 cm; respectively. All for paraffin section and labeled as: S2017-06679FS.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (Moderately differentiated)
      • Microscopic Tumor Extension: To subepithelial connective tissue
      • Margins: Free, Distance from closest margin: 3 mm (superior buccal margin)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes:
        • Ipsilatera (specify)l: level V
        • Number examined: 3
        • Number involved: 0
      • Left maxilla bone: Free of tumor
      • Margins for frozen section, including cheek mucosa, maxillary site, anterior margin, posterior margin: Free of tumor
  • 2017-04-29 MRI - nasopharynx
    • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
  • 2017-04-26 Whole body bone scan
    • No evidence of bone metastasis.
    • Suspected benign lesions in the lower frontal area of the skull, maxilla, mandible, sacrum, bil. shoulders, elbows, and knees.
  • 2017-04-19 Surgical pathology Level IV
    • Left maxilla, biopsy — Squamous cell carcinoma IHC stain p16 (-)

[consultation]

  • 2022-06-24 Radiation Oncology
    • A
      • A: Squamous cell carcinoma of the left mandibular gingiva, stage rpT4aN0(cM0), Stage IVA; s/p operation (Wide excision of the malignant tumor of left mandibular gingiva plus segmental mandibulectomy. Intermaxillary fixation. Complicated extraction of tooth 31, 41, 42. Left fibula osseocutaneous free flap reconstruction. STSG (16*5cm) from the left thigh for wound closure of the left calf).
      • P: Radiotherapy is indicated for this patient with the following indicators: stage rpT4aN0(cM0)
        • Goal: curative
        • Treatment target and volume: left mandibular gingiva tumor bed, peripheral, to bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the left mandibular gingiva tumor bed, peripheral, to bilateral neck, and 6000cGy/30 fractions of the left mandibular gingiva tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-06-30.

[radiotherapy]

[chemoimmunotherapy]

  • 2023-03-03 - cetuximab 250mg/m2 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-16 - cetuximab 250mg/m2 400mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-01-16 - cetuximab 400mg/m2 700mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-26 - docetaxel 40mg/m2 70mg NS 150mL + cisplatin 32mg/m2 60mg NS 150mL 3hr + leucovorin 80mg/m2 150mg & fluorouracil 800mg/2 1500mg NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-12-12
  • 2022-11-21
  • 2022-11-11
  • 2022-10-18
  • 2022-10-11
  • 2022-09-27
  • 2022-09-19
  • 2022-08-16
  • 2022-08-09
  • 2022-07-26
  • 2022-07-19

[assessment]

  • Lab data

    • 2023-03-03 CRP 3.90 mg/dL
    • 2023-02-27 CRP 0.34 mg/dL
    • 2023-02-23 CRP 0.68 mg/dL
    • 2023-02-16 CRP 0.57 mg/dL
    • 2023-03-03 WBC 20.65 x10^3/uL
    • 2023-02-27 WBC 1.34 x10^3/uL
    • 2023-02-23 WBC 1.67 x10^3/uL
    • 2023-02-16 WBC 5.48 x10^3/uL
    • 2023-03-03 HGB 10.4 g/dL
    • 2023-02-27 HGB 7.3 g/dL
    • 2023-02-23 HGB 8.2 g/dL
    • 2023-02-16 HGB 8.8 g/dL
    • 2023-03-03 PLT 198 x10^3/uL
    • 2023-02-27 PLT 210 x10^3/uL
    • 2023-02-23 PLT 230 x10^3/uL
    • 2023-02-16 PLT 249 x10^3/uL
  • According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.

  • The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.

  • The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.

700052706

230302

[exam findings]

  • 2023-02-14 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spines, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2022/08/18, the lesions in the middle T-spines are slightly more evident. Degenerative change in slightly more severe status is more likely. Please correlate with other imaging modalities for further evaluation.
      • No prominent change is noted in other bone lesions.
  • 2023-02-13 SONO - abdomen
    • mild fatty liver (incomplete exam of liver)
    • fatty infiltration of pancreas
  • 2023-02-01 Patho - gingival/oral mucosa biopsy
    • Labeled as “right mandibular gingiva near tooth of #43”, incisional biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-01-20 MRI - nasopharynx
    • History: previous MRI showed an enlarged lymph node (14 mm) at right surpaclavicular fossa. He had received a series of operations on 2022-09-09 at the right buccal mucosa, retromolar trigone area and soft palate.
    • Without- and with-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), and axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm) and axial T1WI with FS (thickness=5 mm, gap=1mm) show:
      • Post-operation change at bilateral buccal regions, with flap reconstruction at left part of palate and buccal region.
      • S/P lymph node dissection on both sides of the neck.
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • A 14-mm lymph node at right supraclavicular fossa, and a 7.5-mm one at left supraclavicular fossa. Stationary as compared with MRI on 20220817.
      • Atrophy with fatty degeneration of left parotid gland.
      • New lesions with diffuse heterogeneous enhancement along right pterygopalatine fossa and pterygoid muscles and temporalis mcsules near right pterygoid plate. Abnormal enhancement also noted along post-operated right posterior buccal region. D/D: recurrence or inflammatory process.
    • IMP:
      • C/W oral cancer s/p treatment, with highly suspicious recurrence along right pterygopalatine fossa and pterygoid plate.
      • Bilateral supraclavicular lymph nodes, stationary as compared with MRI on 20220817.
  • 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • PD-L1 Immunostaining Result, S2022-15256A1
      • Tumor cell (TC) staining assessment: TC >= 1% and < 5%
      • Percent of PD-L1 expression in tumor cells (TC): 1%
  • 2022-09-12 Patho - oral cancer (wide excision without lymph node)
    • Diagnosis
      • Buccal mucosa, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage I, pT1Nx(if cM0)
      • Buccal mucosa, right, posterior tumor margin, re-excision —- Mild dysplasia
      • F2022-00419
        • FsA: Palatoglossal fold, resection margin, biopsy — Negative for malignancy
        • FsB: Oropharynx, resection margin, biopsy — Negative for malignancy
        • FsC: Posterior margin, resection margin, biopsy — Severe dysplasia, at least
        • FsD: Upper posterior margin, resection margin, biopsy — Negative for malignancy
        • FsE: Inferior posterior margin, resection margin, biopsy — Negative for malignancy
        • FsF: Middle inferior margin, resection margin, biopsy — Negative for malignancy
        • FsG: Anterior margin, resection margin, biopsy — Negative for malignancy
        • FsH: Inferior tumor margin, resection margin, biopsy — Negative for malignancy
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma,
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) submucosa
      • Margins (obtained from the main resection specimen): …
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: not received
      • Extranodal extension: not received
      • Additional Pathologic Findings: The posterior tumor margin reveals focal residual squamous epithelium with mild dysplasia.
      • F2022-00419 Sections of the 8 specimens show squamous mucosa and salivary glands without malignancy. Severe dysplasia is seen in posterior margin specimen.
  • 2022-08-18 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spine, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2017/11/14, the lesions in some L-spines are slightly more evident. Degenerative change in slightly more severe status may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Other bone lesions are either stationary or a little less evident, possibly more benign in nature.
  • 2022-08-17 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. Stationary as compared with MRI on 20220304.
  • 2022-08-17 SONO - abdomen
    • renal cyst, bilateral
    • most pancreas masked by gas
  • 2022-08-03 Patho - gingival/oral mucosa biopsy
    • Labeled as “right buccal mucosa”, incisional biopsy — verrucous carcinoma with high grade dysplasia.
    • IHC stain: p16 (-).
  • 2022-03-04 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20210715.
  • 2021-07-15 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20200916.
  • 2020-09-16 MRI - nasopharynx
    • post-OP change in left maxilla floor, hard palate, upper bucco-gingival regions.
    • No local tumor recurrence.
    • No neck LAP.
  • 2020-08-30 CT - abdomen
    • dilated small bowels. suspected small bowel ileus
  • 2020-03-09 MRI - nasopharynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: (comparison: 2019/10/18 MRI)
      • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect of left maxilla floor, hard palate, upper bucco-gingival region. No obvious focal mass or nodule, stationary.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
      • Post resection of left submandibular gland.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the bilateral paranasal sinuses.
      • No obvious abnormal enhancement after contrast medium administration.
    • Impression:
      • Stationary post OP change in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2019-10-22 Surgical pathology level VI
    • Pathologic Diagnosis
      • Buccal mucosa, right, wide excision — Squamous cell carcinoma
      • Resection margins, the same as above and frozen section — Free of tumor invasion
      • Lymph node, submandibular and submental gland, dissection — Free of tumor metastasis (0/5)
      • Lymph node, superficial Level II, the same as above — Free of tumor metastasis (0/2)
      • Lymph node, parotid area, dissection — Free of tumor metastasis (0/1)
      • Lymph node, Level III, dissection — Free of tumor metastasis (fat only)
      • AJCC Pathologic staging — pT1N0Mx, at least stage I.
    • Microscopic Examination
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G1: Well differentiated
      • Microscopic Tumor Extension: 0.35 cm in thickness
      • Margins: Free, less than 0.1 cm from base, 0.1 cm from posterior margin, 0.6 cm from anterior margin, 0.5 cm from superior margin and 0.5 cm away from inferior margin
      • Lymph-Vascular Space Invasion: absent
      • Perineural Invasion: Present
      • Neck Lymph Nodes: free from tumor metastasis (0/8)
      • Salivary gland, submandibular and submental gland LN: chronic sialoadenitis
  • 2019-10-18 MRI - nasopharynx
    • Post-operation change without evidence of recurrence. No evidence of right lower buccogingival lesion based on this study.
  • 2019-10-02 Surgical pathology level IV
    • Right buccal mucosa, biopsy — Squamous cell carcinoma, well differentiated.
    • IHC stain: p16 (-)
  • 2019-05-02 MRI - nasopharynx
    • CC: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01. He complains of dry mouth and pain at his left lower lip area occasionally. The patient became anxious and sought medical attention at both Shuang Ho Hospital and Far Eastern Memorial Hospital, where they received cryotherapy treatment (2018-11-01).
    • Cancer Site-Specific Factors
      • Betel nut chewing [present]: 20 nuts per day, for the past 20 years.
      • Smoking [present]: 20 cigarettes per day, for the past 20 years.
      • Alcohol consumption [none].
    • Indication:
      • S: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01.
      • O: cheilis of both oral commissure combined with fungus infection are noted. leukoplakia of the right palatoglossal fold is still present after injection treatment. chronic abnormal erythymatous lesion on the inner surface of lower lip near left oral commissure are still noted.
      • A: SCC of left maxillary gingiva with bone invasion (cT4aN1M0 before) (2017/11/17 OP) (pT4aN0M0)
      • P:
        • check BUN and creatinine before MRI examination
        • arrange MRI with contrast to evaluate undermining tumor status
    • IMP
      • Post OP in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2018-11-01 MRI - nasopharynx
    • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2018-03-06 MRI - nasopharynx
    • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions.
  • 2017-11-20 Surgical pathology level VI
    • Pathologic Diagnosis
      • Gum, left upper, wide excision — Squamous cell carcinoma, moderately differentiated, with invasion to maxillary sinus, s/p induction chemotherapy
    • Microscopic Examination
      • Histologic Type: Squamous cell carcinoma, s/p induction chemotherapy; The immunohistochemical stain of p16 is negative.
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: (specify) maxillary sinus
  • 2017-11-14 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the left aspect of the maxilla, middle T-spine, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the left aspect of the maxilla. Malignancy with local bone invasion should be watched out. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the middle T-spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • A hot spot in the inferolateral aspect of right orbital area of the skull and some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternocalvicular junctions, hips and knees, compatible with benign joint lesion.
  • 2017-11-13 MRI - nasopharynx
    • Indication: SCC of left maxillary gingiva with bone invasion (cT4aN2bM0)
    • Impression:
      • Residual left maxillary gingiva tumor with bone involvement, in regression
      • compared with previous brain MRI study.
      • paranasal sinusitis.
      • no cervical enlarged LNs.
  • 2017-08-14 Nerve Conduction Velocity, NCV
    • The NCV study showed (1) Prolonged distal motor latency and slowing of sensory nerve conduction velocity in bilateral median nerves. (2) Slowing of motor nerve conduction velocity in left ulnar nerve across elbow. (3) Decreased CMAP amplitude and slowing of motor conduction velocity in left peroneal nerve. (4) Decreased SAP amplitude in left ulnar nerve.
    • The F wave study showed prolonged latency in all sampled nerve of lower limbs. The H reflex showed prolonged latency of left side. The above findings suggest bilateral lumbosacral polyradiculopathy and entrapment neuropathy of bilateral median nerves at the wrist and left ulnar nerve across elbow. Advise careful clinical correlation.
  • 2017-08-12 MRA - brain
    • Indication: SCC of left maxillary gingiva with bone invasion
    • Impression:
      • Essential normal brain MR study.
      • Left chronic paranasal sinusitis

[chemotherapy]

  • 2023-02-22 - cetuximab 250mg/m2 460mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 1000mL] 22hr D2 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-15 - cetuximab 400mg/m2 740mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 500mL] 22hr D2 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-08-30 ~ 2023-02-09 - UFT (tegafur + uracil) KUFT01 2# BID
  • 2017-10-26 ~ 2017-11-16 - UFT 2# BID

[assessment]

  • Leukopenia was observed in the patient, with a count of 1.97 K/uL, on 2023-02-27. This occurred 5 days after the patient received the second cycle of chemoimmunotherapy (cetuximab + TPF).
  • This patient also took UFT from 2022-08-30 to 2023-02-09. As UFT has been discontinued for some time, it is less likely to be the cause of the recent leukopenia.
  • According to the National Health Insurance medication reimbursement regulations, patients with malignant diseases who have experienced leukopenia (less than 1000/uL) or neutropenia (ANC less than 500/uL) after receiving chemotherapy are eligible to use short-acting granulocyte colony-stimulating factor (G-CSF) injections, such as filgrastim or lenograstim.
  • Self-paid G-CSF may be considered by the patient as an option to rapidly increase his white blood cell count.

700280118

230302

[exam findings]

  • 2023-02-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 56) / 132 = 57.58%
      • M-mode (Teichholz) = 58
    • Dilated LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • Thick LVPW, Impaired LV relaxation
  • 2023-01-13 SONO - right knee
    • Right knee joint fluid. The differential diagnosis includes, but is not limited to hemarthrosis, gouty arthropathy.
  • 2023-01-03 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Myelodysplastic syndrome with excess blasts (RAEB-1)
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD71: positive for erythroid series
        • CD61: positive for megakaryocytes
        • CD117: positive for blast
        • CD34: positive for blast
        • CD138: positive for plasma cell
      • Histochemical stain:
        • Reticulin: increased reticulin fibers
    • Microscopically, the sections show pictures as follows:
      • Hypercellularity for his age >90%
      • M/E ratio about 2-3/1, proliferation with left shift maturation of myeloid and erythroid series
      • Proliferative megakaryocytes with nuclear dysplasia and clustering, accompanied by grade 2 (MF-2) reticulin/collagen fibrosis
      • Increased blast (5-9%)
      • Scater distribution of plasma cells
      • Myelofibrosis and osteosclerosis
      • According to all above histopathologic findings, it is suggestive of myelodysplastic syndrome with excess blasts, compatible with RAEB-1 and myelofibrosis. Please correlate with clinical and bone marrow smear findings for conclusive diagnosis.
  • 2022-12-28 SONO - abdomen
    • Splenoemgaly
  • 2022-07-25 Patho - stomach biopsy
    • Stomach, lower body, biopsy — Chronic erosive gastritis, Helicobacter Pylori: NOT present
  • 2022-07-25 SONO - abdomen
    • splenomegaly, mild to moderate
    • pancreas almost not shown
  • 2022-07-25 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Gastric ulcer, multiple, shallow, lower body, s/p biopsy
    • Hiatal hernia
  • 2022-06-17 Patho - gingival/oral mucosa biopsy
    • Labeled as “right buccal mucosa”, excisional biopsy — verrucous hyperplasia, involving un-oriented and unspecified excisional side margin.
  • 2021-11-01 MRI - nasopharynx
    • History: a tongue cancer at the right side was noted and he had received cancer surgeries on 2021-07-07. suspected SCC of right floor of mouth (cT2N2bM0)
    • Indication:
      • S: He is cheek cancer (2016-09) and tongue cancer (2017-03). He finished 3 cycle of induction chemothrapy followed by surgery to remove oral cancer (2016-06).
      • O: Toothace due to gingivitis of residual teeth and residual roots of #22 is noted. red color change on the left palatlglossal fold is noted.
      • A:
        • Verrucous carcinoma of right tongue border (2017-03-15)
        • SCC of left buccal mucosa, lower gingiva and retromolar area, size about 5 cm with suspicous lymph node involment and skin invasion near oral commissure (cT3N1M0 preChemo) (2016-06) (pT2N0M0 postChemo)
      • P:
        • BUN and creatinine before the MRI examination
        • arrange MRI examination to evaluate the underming tumor status
    • Impression:
      • Post OP at right tongue and mouth floor, no obvious focal residual mass
      • Post OP at left bucco-gingival region with neck LNs dissection.
      • No local tumor recurence.
      • No neck LAP.
  • 2021-07-08 Patho - oral cancer (wide excision + lymph node)
    • Oral cavity, right mouth floor, wide excision — Well differentiated squamous cell carcinoma
  • 2021-06-03 Patho - gingival/oral mucosa biopsy
    • Labeled as “right floor of mouth and tongue”, incisional biopsy — Squamous cell carcinoma, well differentiated.
    • IHC stains: CK5/6 (+), p40 (+), p16 (-).
  • 2021-05-19 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, hips, right knee, and left ankle.
  • 2021-05-18 MRI - nasopharynx
    • Post OP at left bucco-gingival region with neck LNs dissection. No local tumor recurence. No neck LAP.
    • No obvious discernible right mouth floor lesion. Stationary and hard to define right tongue or mouth floor tumor? after comparing with 2020/02/11 MRI, need clinical correlation. (revised on 2021/06/10)
  • 2021-02-11 MRI - nasopharynx
    • Post-operation change without evidence of recurrence. Stationary as compared with MRI on 20190402.
  • 2020-02-05 Patho - gingival/oral mucosa biopsy
    • Right floor of mouth? biopsy — Verrucous hyperplasia. Please excise entire lesion for further patholoigcal evaluation.
  • 2019-04-02 MRI - nasopharynx
    • Post-operation change without recurrence. Stationary as compared with MRI on 20180828.
  • 2018-10-02 Surgical pathology level IV
    • Oral cavity, right, buccal mucosa, laser remove — Verrucous carcinoma — margin free
  • 2018-08-28 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2018-01-03 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2017-06-22 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2017-03-15 Surgical pathology level IV
    • Tongue, right border, wide excision —- Verrucous carcinoma
    • Pathology stage: pStage I, pT1 Nx (cMx)
  • 2017-01-03 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.

[consultation]

  • 2021-06-23 Hemato-Oncology
    • Q
      • This is a 51-year-old male who had medical history of squamous cell carcinoma of left bucco-gingival region with retromolar extension and possible anterior skin invasion, cT4aN1M0 status post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa thereafter. He didn’t return to OPD follow-up until this time with a painless malignant tumor with firm texture on the right floor of mouth and ventral tongue. After thorough tumor work-up, he was diagnosed with squamous cell carcinoma of right floor of mouth, cT2N2bM0. This time, he was admitted for surgical intervention. However, his platelet count was lower than average (50x10^3/uL) without any underlying known cause and coagulation defiency. Therefore, we need your expertise for further survey of idiopathic thrombocytopenia.
    • A
      • The 51 y/o male, a pt of L bucco-gingival SCC wt retromolar extension and possible anterior skin invasion, cT4aN1M0 s/p post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa, was noted to have thrombocytopenia just before Op in June 2021.
      • The definite diagnosis of thrombocytopenia is to be under further investigation.
      • Image
        • Abd sono (20210520): splenomegaly.
      • Lab data
        • Hb (20210622):15.6, MCV:95.0, MCHCL34.5, plt:50K, WBC:3600
        • Hb (20210517):15.9, MCV:96.0, MCHC:34.6, plt:51K, WBC:4270
        • LFT & RFT (20210622): normal
        • HBsAg & antti-HCV (20210519): negative.
      • Dx: Thrombocytopenia, cause ? R/I splenomegaly related R/I idiopathic thromcytopenic purpura (ITP) R/I autoimmune related
      • Medical advice:
        • By Tracing his medical history, thrombocytopenia has been noted recently in May & June 2021.
          • Abd CT (20210520) showed splenomeagly. Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia.
        • May check Rheumatoid factor & ANA to exclude possible autoimmune dz. But autoimmune dz very rarely occurs in male pt. 
          • By clinical pictures, hematologic dz, TTP with toxic S/S, or DIC by infection were less likely to be the causes of thrombocytopenia of this pt. 
          • Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia if RF & ANA show negative.
        • If RF or ANA shows positive, may consult rheumatologist for further Tx. Tx of underlying autoimmune Dz may improve thrombocytopenia or may try prednisolone 1mg/kg/day for 2 weeks. If no response, splenectomy or IVIG or immunosuppressant (eg: Azathioprin, cyclophosphamide or Vincristine ) may be tried.
        • The current platelet count 50 K/uL is safe for this pt if no trauma happens. If platelet count requirement for Op is above 100K /uL, may consider platelet transfusion wt single donor ( pheresis ) platelet transfusion which is more effective to elevate platelet count & may less induce autoAb that will cause poor response to next platelet transfusion in the future.
          • But it is hard for pt wt splenomegaly related thrombocytopenia to elevate plt count by plt transfusion.

[chemotherapy]

  • 2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

  • 2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

  • 2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01

[assessment]

  • Lab data

    • WBC
      • 2023-03-01 WBC 21.51 x10^3/uL
      • 2023-02-27 WBC 3.45 x10^3/uL
    • HGB
      • 2023-03-01 HGB 7.4 g/dL
      • 2023-02-27 HGB 9.3 g/dL
    • PLT
      • 2023-03-01 PLT 16 x10^3/uL
      • 2023-02-27 PLT 3 x10^3/uL
      • 2023-02-26 PLT 7 x10^3/uL
      • 2023-02-24 PLT 17 x10^3/uL
      • 2023-02-22 PLT 12 x10^3/uL
      • 2023-02-19 PLT 6 x10^3/uL
      • 2023-02-17 PLT 4 x10^3/uL
      • 2023-02-15 PLT 1 x10^3/uL
      • 2023-02-14 PLT 2 x10^3/uL
      • 2023-02-13 PLT 1 x10^3/uL
      • 2023-02-12 PLT 1 x10^3/uL
      • 2023-02-11 PLT 1 x10^3/uL
      • 2023-02-10 PLT 1 x10^3/uL
      • 2023-02-09 PLT 1 x10^3/uL
      • 2023-02-09 PLT 1 x10^3/uL
      • 2023-02-08 PLT 7 x10^3/uL
      • 2023-02-08 PLT 3 x10^3/uL
      • 2023-02-07 PLT 2 x10^3/uL
      • 2023-02-06 PLT 1 x10^3/uL
      • 2023-02-04 PLT 3 x10^3/uL
      • 2023-02-03 PLT 1 x10^3/uL
      • 2023-02-02 PLT 2 x10^3/uL
      • 2023-02-01 PLT 3 x10^3/uL
      • 2023-01-30 PLT 5 x10^3/uL
      • 2023-01-18 PLT 6 x10^3/uL
      • 2023-01-16 PLT 7 x10^3/uL
      • 2023-01-13 PLT 10 x10^3/uL
      • 2023-01-11 PLT 9 x10^3/uL
      • 2023-01-10 PLT 6 x10^3/uL
      • 2023-01-08 PLT 5 x10^3/uL
      • 2023-01-06 PLT 3 x10^3/uL
      • 2023-01-05 PLT 5 x10^3/uL
      • 2023-01-03 PLT 15 x10^3/uL
      • 2023-01-02 PLT 7 x10^3/uL
      • 2022-12-31 PLT 7 x10^3/uL
      • 2022-12-27 PLT 9 x10^3/uL
      • 2022-12-27 PLT 7 x10^3/uL
      • 2022-07-13 PLT 15 x10^3/uL
      • 2022-03-29 PLT 24 x10^3/uL
      • 2021-07-12 PLT 44 x10^3/uL
      • 2021-07-09 PLT 74 x10^3/uL
      • 2021-07-07 PLT 125 x10^3/uL
      • 2021-07-06 PLT 153 x10^3/uL
      • 2021-07-05 PLT 77 x10^3/uL
      • 2021-06-22 PLT 50 x10^3/uL
      • 2021-05-17 PLT 51 x10^3/uL
  • According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.

  • Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006

  • In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.

  • Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6

  • There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995

701201523

230302

[diagnosis]

  • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
  • Relapsed small lymphocytic lymphoma involving multiple lymph nodes as of bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions ,Lugano stage IV, PS:1
  • Essential (primary) hypertension
  • Chronic viral hepatitis B without delta-agent

[exam findings]

  • 2022-12-12 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2022-11-25 CT - chest
    • Lymphadenopathy at left lower neck. Statioanry.
    • Lymphadenopathy at mesenterric and paraaortic region. In progression.
  • 2022-07-29 CT - chest
    • Extensive lymphadenopathy at bilateral lower neck, axillary, and mesenterric region. Stationary in size.
  • 2022-04-15 CT - chest
    • Lymphadenopathy at left supraclavicular region and bilateral axillary region, paraaortic and mesenterric region. In regression.
  • 2022-01-06 CT - chest
    • Lymphadenopathy at bilateral thoracic inlet and axillary, mediastinal and abdominal paraaortic and paracaval region. In regression.
  • 2021-10-19 CXR
    • Atherosclerotic change of aortic arch.
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2021-10-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 19) / 74 = 74.32%
      • M-mode (Teichholz) = 74
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; moderate TR; mild PR.
  • 2021-10-06 CT - chest
    • advanced malignant lymphoma involving both sides of diaphgram, stationary as compared with previous CT study on 2021/04/13
  • 2021-04-13 CT - chest
    • advanced malignant lymphoma involving neck both sides of diaphgram, seem stationary as compared with previous CT study on 2020/12/22
  • 2020-12-22 CT - chest
    • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2020/07/15
  • 2020-07-15 CT - chest
    • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2019/12/05
  • 2019-12-17 Surgical patholgoy Level IV
    • Clinical diagnosis: Lymphoma, other named variants, LN of head face and neck;
    • Pathological diagnosis:
      • Bone marrow, iliac, biopsy — Lymphoma involvement.
      • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+).
    • Microsopic description
      • Section shows one piece of bone marrow with 50% cellularity and M:E ratio of approximately 5:1. There is a predominant subpopulation of small lymphoid cells.
      • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+), compatible with clinical history of small lymphocytic lymphoma.
  • 2019-12-05 CT - abdomen
    • Enlarged LNs at bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions c/w lymphoma.
  • 2019-11-01 PET
    • There was mildly or faintly increased FDG uptake involving multiple lymph nodes (SUVmax early: 1.10, delay: 1.15) including multiple bilateral neck, bilateral supraclavicular and axillary lymph nodes, some mediastinal, abdominal and bilateral inguinal lymph nodes. There was increased FDG uptake in the nasopharynx (SUVmax early: 1.94) and stomach (SUVmax early: 2.84, delay: 1.79).
    • IMPRESSION:
      • Mild or faint glucose hypermetabolism involving multiple lymph nodes as mentioned above. Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm should be watched out. Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in the nasopharynx and stomach. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.

[chemoimmunotherapy]

  • 2023-03-01 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-06 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-12-13 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-03-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-02-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-01-03 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-12-07 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-11-09 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-10-19 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

[assessment]

  • This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.

  • The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.

  • Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.

700207892

230301

[present illness] - 2023-02-27 admission note

  • The 44 year old woman has history of
    • Renal stone /p ESLW once and /p URS on 2018
    • Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV under Leukeran (chlorambucil) 2mg 1# qd treatment on 2021/05 ~ 2022.

[past history]

  • medication history:
    • small lymphocytic lymphoma/ chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV, ECOG:  1
  • operation history:
    • Renal stone s/p ESLW and URS
    • anal fissure and mixe dhemorhroids s/p operation
    • right thigh intramascular abscess s/p debridement                    

[allergy]

  • NKDA     

[family history]

  • no family history of DM, CAD, CVA and cancer

[exam findings]

  • 2022-10-13 Patho - abscess
    • Labeled as “right thigh soft tissue”, clinical history of chronic lymphocytic leukemia, debridement — chronic inflammation.
    • IHC stains: CD3 and CD20 show no predominant sub-population.
  • 2022-10-08 MRI - lower extremity
    • Indication: Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV
    • MRI of lower extremity without/with Gadolinium-based contrast enhancement shows:
      • swelling of right anterior thigh muscle (mainly rectus femoris) with a rim-enhancing intramuscular mass lesion (about 3.1x2.4x4.5cm) with central necrosis. Marked adjacent subcutaneous fat stranding and superficial fascial fluid collection is noted. An intramuscular abscess is first considered. Suggest follow up after treatment to exclude lymphoma involvement.
      • clustered enlarged inguinal lymph nodes.
      • no abnormal bone marrow edema nor hyperemia.
    • Impression:
      • Favor an intramuscular abscess (about 3.1x2.4x4.5cm) at right anterior thigh. Suggest follow up after treatment to exclude lymphoma involvement.
  • 2022-08-23 Patho - fissure/fistula
    • Anus, PIS — Anal fissure
  • 2022-08-12 Abdomen - standing (diaphragm)
    • There is hepatosplenomegaly. please correlate with clinical condition
  • 2022-06-29 CT - abdomen
    • Indication: intermittent, whole abdominal dull pain for 3 days
    • IMP:
      • no evidence of free abdominal air.
      • a nodular lesion, about 14mm, in the spleen. Nature?
  • 2022-06-04 CT - brain
    • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
    • Impression:
      • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2021-05-27 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Small lymphocytic lymphoma / chronic lymphocytic leukeima
    • The sections show hypercellular marrow (>90%) for her age with small lymphocytes proliferation. Immunohistochemistry of CD20(+), CD3(-), CD5(+), CD23(+), Bcl2(+), CD34(-), CD61 showed adequate megakaryocyte, CD71 showed mild decreas of erythroid series and MPO showed decreased myeloid series. Clinical correlation is advised.
  • 2021-05-25 CT - abdomen
    • Lymphoma in paraaortic, iliac and pelvic cavity, inguinal regions. Progression.
    • Splenomegaly with splenic nodule, progression, suspected lymphoma.
  • 2021-01-05 CT - abdomen
    • Splenomegaly.
    • Lymphadenopathy at paraaortic and mesenterric region. Stable.
  • 2020-09-25 CT - abdomen
    • Lymphoma S/P C/T show stable disease.
  • 2020-07-01 Whole body PET scan
    • Glucose hypermetabolism in bilateral cervical lymph nodes, bilateral axillary lymph nodes, pelvis, and bilateral inguinal lymph nodes, lymphoma should be the first considered.
    • Glucose hypermetabolism in bnilateral palatine tonsils, reactive change resulting from locoregional inflammation may show such a picture.
    • Lymphoma (if proved), stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-06-12 Patho - lymphnode biopsy
    • Lymph node, right inguinal, excision —– Small lymphocytic lymphoma / chronic lymphocytic leukemia
    • Histology type: B-cell neoplasms: B-lymphoblastic lymphoma/leukemia
    • Immunohistochemical stain profiles: CD20(+), CD3(-), CD5(+), BCL2(+), CD23(+), CD43(+), SOX11(-), Cyclin D1(-), BCL6(-), CD10(-). The Ki-67 is about 15%.
  • 2020-06-12 CT - abdomen
    • Lymphoma is highly suspected.
    • The differential diagnosis include metastases.
  • 2020-06-10 Patho - bone marrow biopsy
    • clinical diagnosis: D72.829 Elevated white blood cell count, unspecified
    • Bone marrow, iliac, biopsy — B cell lymphoma.
    • IHC stains: CD34: 1%; MPO: approximaltely: 10%; LCA (+, 80-90%); CD20: a predominant monoclonal subpopuation. CD3: few.
    • Additional IHC stains: bcl-2 (diffuse +++), bcl-6 (-), CD23 (+++), cyclin-D1 (-).
    • The IHC pattern is that of a small lymphocytic lymphoma / chronic lymphocytic leukeima.
    • Section shows one piece of bone marrow with 60-70 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and a predominant subpopulation of small round blue cells. Megakaryocytes are adequate in number. B cell lymphoma.
  • 2020-06-09 CXR
    • A nodular opacity projecting in the left upper lung is suspected that may be left 1st rib cartilage calcification or true lesion? Follow up is indicated. Otherwise, Please correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.

[chemoimmunotherapy]

  • 2023-02-27 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1450mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-30 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-04 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-12-13 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-11-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-05-26…2021-07-04 - Leukeran (chlorambucil 2mg/tab) KLEUK BID PO

[G-CSF]

  • Granocyte (lenograstim) CGRAN01
    • 2022-11-29 ~ 2022-11-30 250ug SC 2022-11-17 IPD
    • 2022-08-27 ~ 2022-08-26 250ug SC 2022-08-12 IPD
  • G-CSF (filgrastim) CGCSF01
    • 2023-02-27 150ug SC 2023-02-27 IPD self-paid
    • 2022-08-12 300ug SC 2022-08-12 IPD

[assessment]

  • It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.

  • Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.

700853234

230301

[exam findings]

  • 2023-02-27 CXR
    • small Lt hemithorax, decreased pulmonary vascularity, and small hilum, due to fibrotic and bronchiectatic change
    • extensive mixed consolidation and hazy increased opacity over Rt lower lung zone
    • pathological compression fracture of multiple vertebral bodies
    • compression fracture of L2 vertebral body priop vertebroplasty
  • 2023-02-07 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple C-, T- and L-spines, bilateral multiple ribs and bilateral pelvic bones.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2023-02-03 MRI - spine
    • Diffuse bony metastases involving C2-T12 vertebral bodies and bilateral ribs. LUL lesion, suspected metastases.
    • Diffuse bony metastases involving vertebral column (T10-S1) and iliac bones. Recent compression fratucre of L1 vertebral body, pathologic? S/P VP at L4 vertebral body.
  • 2023-02-03 ECG
    • Sinus tachycardia with Premature atrial complexes
  • 2023-02-01 T-spine AP + Lat
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
    • Presence of thoracic-lumbar spinal kyphosis, mild.
  • 2023-02-01 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
    • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at L4.
  • 2022-09-21 CT - abdomen
    • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
      • 20220426 colonoscopy: R/O A-colon cancer with obstruction. pathology: Signet-ring cell carcinoma
      • 20220504 CT:T4bN2aM0, cSTAGE:IIIC
      • 20220511 S/P right hemicolectomy:Advanced A-colon CA wt peritoneal seeding, pT4aN2bM1c , stage IVC
    • Indication: A-colon cancer S/P C/T for FU
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P right hemicolectomy
      • There is minimal ascites in the cul-de-sac.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
      • Prior CT identified two confluent cystic dilatation lesion in LUL and LLL of the lung are noted again, stationary.
        • Bronchiectasis are highy suspected.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P right hemicolectomy.
      • There is no evidence of tumor recurrence.
  • 2022-09-21 CXR
    • Fibrosis of left upper lung is noted. Please correlate with clinical history to rule out old inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-05-12 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Ascending colon, right hemicolectomy — Signet-ring cell carcinoma
      • Resection margins, bilateral, ditto — Free of tumor
      • Lymph node, mesocolic, dissection — Tumor metastasis (14/18) with extracapsular extension (7/14)
      • Appendix, right hemicolectomy — Appendiceal wall invasion
      • Omentum tissue, ditto — Signet-ring cell carcinoma
      • AJCC pathologic stage — pT4aN2bM1c, stage IVC
    • MACROSCOPIC EXAMINATION
      • Operation procedure: right hemicolectomy
      • Specimen site: Ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 22.5 cm in length, up to 5.2 cm in diameter with some omentum tissue, (b) Terminal ileum: 6.5 cm in length, 2.7 cm in diameter; (c) Appendix: 3.4 cm in length, 0.3 cm in diameter
      • Tumor size: 6.9 x 4.8 cm
      • Tumor location: 15 and 6.5 cm away from bilateral resection margins
      • Tumor appearance: protruding mass
      • Depth of invasion grossly: visceral peritoneum
      • Representative sections as A1: ileum + colonic margin, A2: appendix, A3: tumor + radial margin, A4-A6: tumor + serosal layer, A7-A8: tumor, A9-A12: lymph nodes, A13: omentum nodules
    • MICROSCOPIC EXAMINATION
      • Histology: signet-ring cell carcinoma with abundant mucin production
      • Histology Grade: G3, poorly differentiated
      • Depth of invasion: visceral peritoneum
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: not identified.
      • Circumferential (radial) margin of rectosigmoid: involved
      • Lymph node metastasis, mesocolic: tumor metastasis (14/18)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: Present (7/14)
      • Pathological TNM Stage: pT4aN2bM1c
      • Type of polyp in which invasive carcinoma arose: N/A
      • Omentum tissue: tumor deposition
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A
      • Appendix: appendiceal wall invasion
  • 2022-05-10 CT - chest
    • post infectios or inflammatory fibroticalcified change of lungs
    • with bronchiectasis/bronchiolitis and volume loss especially left lung.
  • 2022-05-10 Flow volume chart
    • mild restrictive impairment
  • 2022-05-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 15) / 74 = 79.73%
      • M-mode (Teichholz) = 79.5
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR and PR
  • 2022-05-04 CT - abdomen
    • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
      • 20220426 colonoscopy: R/O colon cancer with obstruction at hepatic flexture. pathology: Signet-ring cell carcinoma
    • Indication: colon cancer, hepatic flexure for staging
    • Findings:
      • There is asymmetrical wall thickening with whole layer involvement and irregular outer margin at the ascending colon, ileo-cecal valve and terminal ileum, measuring 7.5 cm in length. The adjacent omentum shows fatty stranding and suspicious soft tissue nodules.
        • Adenocarcinoma of the ascending colon with direct invasion the adjacent omentum (T4b) is highly suspected.
        • In addition, There is are four enlarged nodes in the adjacent mesocolon (N2a).
      • There is minimal ascites in the cul-de-sac.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
      • There are two confluent cystic dilatation lesion in LUL and LLL of the lung that may be bronchiectasis? Please correlate with chest CT.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-04-26 Patho - colon biopsy
    • Colon, hepatic flexure, biopsy — Signet-ring cell carcinoma
    • Section shows pieces of colonic tissue with invasive signet-ring cells.
    • The immunohistochemical stains reveal CK7(-) and CK20(+), EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • Please correlate with the clinical presentation and image study to exclude other primary origin.
  • 2022-04-26 Colonoscopy
    • Suspected colon cancer, hepatic flexure, s/p biopsy
    • Suspected lumen stricture, hepatic flexure
    • Mixed hemorrhoid
  • 2018-02-12 MRI - L-spine
    • Recent compression fracture of L4 vertebral body
    • Mild central HIVD, L3-L4.
    • Disc bulge with fissure of posterior annulus, L4-L5
    • Disc bulge with tear fissure, L2-L3.

[surgical operation]

  • 2022-05-11
    • Surgery: Right hemicolectomy        
    • Finding: large A-colon cancer withmesentary LN enlargement R/O Omental carcinomatosis and tumor seeding on viceral peritoneum
  • 2018-02-13
    • Diagnosis: L4 compression fracture
    • PCS code: 64160B

[chemoimmunotherapy]

  • 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3170mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-09-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3220mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-08-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3235mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-07-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-06-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-06-09 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[assessment]

  • A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.

  • The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.

701462331

230301

[present illness]

  • The 72-year-old men has had history of
    • Hypertension for more than 5 years under regular medication treatment at CGMH
    • Coronary artery disaeae post stent for more than 10 years under regular medication treatment at CGMH
    • Gallbladder stone
    • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH
    • Right clavicle fracture s/p plating, union on 2003/10/27
    • Diagnosis lung cancer in ECKH (En Chu Kong Hospital) 2022/11/23, status post Tarceva (erlotinib) since 2022/11/25, change to Giotrif (afatinib) since 2022/12/08.

[past history] - 2023-02-25 admission note

  • Hypertension for more than 5 years under regular medication treatment at CGMH.
  • Coronary artery disaeae post stent for more than 10years under regular medication treatment at CGMH.
  • Gallbladder stone.
  • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH.
  • Right clavicle fracture s/p plating, union on 2003/10/27.
  • COVID-19 infection on 2022/06     

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, mental diseases or asthma.
  • No members of the family with diabetes.   

[exam findings]

  • 2023-02-25 - CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2023-02-01 CT - chest
    • Indication: Lung adenocarcinoma with lung to lung mets, cT4N3M1a, TTF-1 (+)
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT )other hospital) dated on 2022/11/16
      • Lungs: diffus reticular and small nodules opacities over both lungs, with subpleural ground glass opacity over Rt lower lobe.
      • Mediastinum and hila: extensive lymphadenopathy in the visceral space and left anterior prevascular space and both hila/ small calcifiecations are noted, may be sequela of previous TB infection
        • extensive coronary arterial calcification.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace Rt-sided effusion.
      • Chest wall and visible lower neck: small LNs at Lt supraclavicular fossa.
      • Visible abdominal contents: gall bladder stone (20mm).
        • no focal lesion in visible portion of liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: RLL cancer with lung to lung (hematogeneous, lyphaphatic routes) and mediastinal-hilar LNs metastases in regression compared with CT on 2022/11/16, and suspect RLL fibrosis extensive 3V-CAD
  • 2023-02-01, -01-19, -01-05, 2022-12-22, -12-01 CXR
    • There are multiple nodular opacities projecting at both lung that are c/w lung to lung metastases after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-12-01 Patho - lung transbronchial biopsy
    • Lung, RB7a, TBLB — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma. The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-12-01 Cell Block
    • Indication: multiple metastatic lung nodules, ADC proved by CGMH, but origin unknown
    • Result: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK(+), TTF-1(+), and Calretinin(-). The results are consistent with meatstatic adenocarcinoma from lung. Please correlate with the clinical presentation.
  • 2022-12-01 Bronchoscopy
    • Chronic rhinitis with post-nasal drip
    • Multiple mucosa anthrocosis change
    • No any visible endobronchial lesion
    • RB7 para- and peribronchial lesion, s/p TBLB.

[medication]

  • 2022-12-08 ~ undergoing - Giotrif (afatinib 30mg/tab) KGIOT03 QDAC
  • 2022-11-25 ~ 2022-12-?? - Tarceva (erlotinib)

[assessment]

  • Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.

  • The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.

  • After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.

  • The current prescription is without any issue.

700838300

230224

[diagnosis] - 2023-02-23 admission note

  • Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
  • Malignant neoplasm of unspecified site of right female breast
  • Mastodynia
  • Essential (primary) hypertension
  • Insomnia, unspecified
  • Constipation, unspecified

[past history] - 2022-12-08 admission note

  • The patient has history of hypertension under medication treatment.
  • history of operation: s/p bilateral mammoplasty.
  • G2P0SA2
  • Breast feeding (-)
  • menarche : 13y/o
  • menopause: y/o
  • Hormone therapy: (+) due to In Vitro Fertilization
  • Family history of breast cancar: NIL       

[lab data]

  • 2022-08-29 HBsAg Negative
  • 2022-08-29 HBsAg Value 0.524
  • 2022-08-29 Anti-HCV Negative
  • 2022-08-29 Anti-HCV Value 0.0352
  • 2022-08-29 Anti-HBc Nonreactive
  • 2022-08-29 Anti-HBc-Value 0.19 S/CO
  • 2022-06-29 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
  • 2022-06-29 Anti Jo-1 antibody <0.3 EliA U/ml
  • 2022-06-29 Anti-ENA SS-A(Ro) <0.3 EliA U/ml
  • 2022-06-29 Anti-ENA SS-B(La) <0.3 EliA U/ml
  • 2022-06-29 ANA Negative

[exam findings]

  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 22) / 89 = 75.28%
      • M-mode (Teichholz) = 76
    • Normal chambers sizes
    • Normal LV and RV systolic function.
    • Typical mitral valve prolapse ( anterior leaflet); mild PR.
    • poor apical echo window due to previous mammloplasty procedure.
  • 2022-12-10 CT - chest
    • Indication: Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p op. over right axillary region is found. Some fibrotic mass like lesion at op region. Regional lymph nodes are also found.
      • Calcified dot at uncinate process of the pancreas is found.
    • Imp:
      • Right axillary soft tissue mass with lymph nodes.
      • Calcified dot at uncinate proces of the pancreas.
  • 2022-10-05 Pap Smear Test (for cervical cancer screening)
    • Atypical squamous cells (ASC-US)
  • 2022-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 26.8) / 72.1 = 62.83%
      • M-mode (Teichholz) = 62.8
    • Normal AV with no AR
    • Normal MV with no MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
  • 2022-08-11 Patho - breast biopsy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, right breast, frozen+ partial mastectomy —- Invasive carcinoma of no special type
      • Resection margins, frozen section — Free, closest 0.2 cm at upper side of 1 o’clock margin
        • 12 o’clock margin, recut — Free of tumor invasion
      • Skin, ditto — Free of tumor invasion
      • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (2/4) without extracapsular extension (0/2)
        • Lymph node, R’t level I, dissection — Free of tumor metastasis (0/14)
        • Lymph node, R’t level II, dissection — Free of tumor metastasis (0/7)
      • Cyst, R’t chest wall, excision — Epidemal cyst
      • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type with focal ductal carcinoma in situ, low grade
      • Size of invasive carcinoma: 1.1 x 0.9 cm
      • Histologic grade (Nottingham histologic score): Grade I (score 5) including (A) Tubule formation: score 2; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]. Besides, focal ductal carcinoma in situ, low grade arranged in cribriform pattern is also noted
      • Margins: Free, closest 0.2 cm away from upper side of 1 o’clock, 2.6 cm from 12 o’clock, 1.1 cm from 3 o’clock, 2.6 cm from 9 o’clock, 2.4 cm from 6 o’clock and 0.5 cm from base
      • Nodal status:
        • R’t axillary SLNs: Tumor metastasis (2/4) without extracapsular extension (0/2)
        • R’t level I: Free of tumor metastasis (0/14)
        • R’t level II: Free of tumor metastasis (0/7)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: present
      • Perienural invasion: Not identified
      • Immunohistochemistry: Please refer to S2022-11514
  • 2022-08-11 Frozen Section
    • Margins, right breast, frozen section — Free, closest margin 0.3 cm at 12 o’clock and 0.2 cm at upper side of 1 o’clock margin
    • Sentinel lymph nodes, right axilla, ditto — Tumor metastasis (2/4)
  • 2022-08-11 Lymphoscintigraphy
    • Finding
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • Impression
      • Probably a sentinel lymph node at the right axillary region.
  • 2022-07-28 Tc-99m MDP whole body bone scan with SPECT
    • Mildly increased activity in lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the nasal bon. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral elbows, hips and knees, compatible with benign joint lesions.
  • 2022-07-25 SONO - abdomen
    • Calcified spots in the liver.
    • Liver cysts.
    • Gallbladder stone.
  • 2022-07-18 Patho - breast biopsy
    • Breast, right, 1/3 tumor, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, strong intensity), PR(+, 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(<10 %), p53 (<10%).
  • 2022-06-28 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Suspected right breast tumor (#2)
      • S/P bil. mammoplasty
    • Suggestion
      • tissue study
    • BI-RADS:
      • suspicious abnormality, biopsy should be considered
  • consultation
    • 2022-08-16 Dermatology
      • Q
        • For dermatitis
        • This 41 y/o female a case of right breast cancer. She underwent right partial mastectomy + ALND on 20220811. She has noted dermatitis at forehead, without itch. We need your expertise for dermatitis evaluation and treatment.
      • A
        • The patient had sufferred from facial and scalp erythematous papules
        • Under the impression of seborrheic dermatitis
        • The following sugeetion:
          • Topysm lotion 2 bot. topical bid use on the scalp lesions.
          • Rinderon-V cream 1 tube topical bid use on the facial and post-aucurial area.

[surgical operation]

  • 2022-08-11
    • Surgery
      • right partial mastectomy and ALND (axillary lymph node dissection)
      • tumor excision
    • Finding
      • right 1/3 tumor, about 1cm in diameter
      • SLNB (sentinel lymph node biopsy): positive of malignancy, 2/4
      • epidermoid cyst over right chest wall, LIQ, no infection

[chemoimmunotherapy]

  • 2023-02-23 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 950mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-28 - doxorubicin 60mg/m2 94mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-08 - docetaxel 75mg/m2 115mg NS 250mL 1hr + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-17 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-26 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-23 - docetaxel 60mg/m2 90mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • G-CSF (granulocyte colony stimulating factor)
    • 2022-12-17, -18, -19 (20221217 OPD)
    • 2022-11-26, -27, -28 (20221126 OPD)
    • 2022-11-20, -21, -22 (20221117 IPD)
    • 2022-10-29, -30, -31 (20221026 IPD)
  • Low WBC data points
    • 2022-12-17 WBC 1.29 *10^3/uL
    • 2022-11-26 WBC 2.59 *10^3/uL
    • 2022-10-04 WBC 1.34 *10^3/uL

==========

2023-02-24

  • The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.

  • For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.

  • The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.

    • For patients with mild lymphedema (ISL stage I), it is suggested physiotherapy in the form of manual lymphatic drainage and compression garments, rather than more intensive therapy. Manual lymphatic drainage (MLD) is a massage-like technique that is typically performed by specially trained physical therapists, but a self-help maneuver (simple lymphatic drainage) has also been used for mild cases. Light pressure is used to mobilize edema fluid from distal to proximal areas.
    • For patients with moderate-to-severe lymphedema (ISL stages II to III) and no contraindications, it is suggested intensive physiotherapy, usually in the form of complete decongestive therapy, rather than less intense therapy. Complete decongestive therapy (CDT) refers to a two-phase (treatment phase, maintenance phase) multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures.
    • Patients with severe lymphedema (ISL stage III) may also benefit from intermittent pneumatic compression (IPC) in addition to CDT. IPC (also called sequential pneumatic compression) devices employ a plastic sleeve or stocking that is intermittently inflated over the affected limb. Most pneumatic compression pumps sequentially inflate a series of chambers in a distal-to-proximal direction.
  • This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.

  • No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

2022-12-09

  • 2D transthoracic echocardiography performed on 2022-12-19 and 2022-08-29 did not demonstrate deteriorations in heart function.

2022-11-18

  • Docetaxel has been associated with adverse dermatologic reactions: Alopecia (56% to 76%, can be permanent), dermatological reaction (20% to 48%; severe dermatological reaction: 5%), nail disease (11% to 41%). There have also been reports of adverse reactions associated with cyclophosphamide: Alopecia, changes in nails, dermatitis, erythema multiforme, erythema of skin, hyperhidrosis, palmar-plantar erythrodysesthesia, pruritus, skin abnormalities related to radiation recall, skin blister, skin rash, skin toxicity, Stevens-Johnson syndrome (Assier-Bonnet 1996), toxic epidermal necrolysis (Sasak 2016), urticaria (Thong 2002).
  • It is not recommended to immediately reduce the dose of chemotherapy once a mild adverse reaction has been observed in order to gain expected therapeutic effect. Skin symptoms are currently treated with drugs prescribed by dermatologists.
  • The underlying conditions of hypertension, constipation, mastodynia, and insomnia are all appropriately treated with appropriate medication without a problem.

2022-10-06

  • A rise in serum creatinine has been observed over the last three months, while the patient has been taking several NSAIDs, including Tonec (aceclofenac), Arcoxia (etoricoxib), and Volna-K (diclofenac). If NSAIDs are required for myositis and/or mastodynia, the renal function should be routinely monitored.
    • 2022-10-04 Creatinine 0.70 mg/dL
    • 2022-09-23 Creatinine 0.64 mg/dL
    • 2022-08-10 Creatinine 0.55 mg/dL
  • For this patient with ER(+), PR(+) and HER2(-) breast cancer, the current adjuvant chemotherapy might be followed by endocrine therapy (e.g., aromatase inhibitor or tamoxifen).

700851656

230224

[exam findings]

  • 2023-02-17 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-02-17 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH (left ventricular hypertrophy), may be normal variant
    • Borderline ECG
  • 2022-09-23 SONO - nephrology
    • chronic parenchymal renal disease
  • 2022-01-28 Merchant view (patella 45 0) Rt
    • No lateral subluxation or lateral tilting of the patella
    • Patellofemoral osteoarthritis
    • Sperner classification: 4
  • 2022-01-28 Knee Rt standing AP and Lat views
    • Severe osteoarthritis of right knee with valgus deformity
    • Ahlback calcification: grade 4
  • 2021-11-04 Patho - colorectal polyp
    • Mid transverse colon, polypectomy — Tubular adenoma, low grade
    • Proximal transverse colon, polypectomy — Tubular adenoma, low grade
  • 2021-07-02 SONO - nephrology
    • chronic parenchymal renal disease
    • distended urinary bladder
  • 2021-06-28 CT - abdomen
    • Bilateral kidney atrophy
    • Lumbar spondylosis
  • 2020-12-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcer scars, bulb
      • Superficial gastritis, antrum, s/p CLO
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • PPI use
      • Pend for CLO
  • 2020-08-01 SONO - abdomen
    • Diagnosis
      • liver parenchyma disease
      • gallstones, GB wall thickening
      • suspect renal parenchyma disease
    • Suggestion
      • correlate with kidney echo
  • 2020-07-30 CXR
    • Increased bilateral lung markings.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2020-07-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 45.4) / 104 = 56.35%
      • M-mode (Teichholz) = 56.3
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR, AR, PR
    • Mild Pulmonary HTN
  • 2020-07-28 CXR
    • Mild increased infiltration in both lungs
    • No pleural lesion
    • Borderline enlarged cardiac sihoutte
  • 2020-05-08 SONO - nephrology
    • chronic parenchymal renal disease
  • 2020-04-30 CXR
    • Increased bilateral lung markings.
    • Borderline cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2020-04-30 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left ventricular hypertrophy
    • Nonspecific ST abnormality
    • Abnormal ECG

[assessment]

  • Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.

  • For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.

  • Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.

701296927

230224

{not completed}

[diagnosis]

  • K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.

[past history]

  • Denied history of Hypertension        

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer

[exam findings]

  • 2023-01-02, 2022-12-20, -12-15 Abdomen - Standing (Diaphragm)
    • Ascites is noted.
    • S/P clips projecting at RUQ and LMQ abdomen, and pelvis.
    • Spondylosis of the L-spine is noted.
    • 2023-01-02 Partial Small bowel obstruction with partial resolving is suspected. Follow up is indicated.
    • 2022-12-20 Partial Small bowel obstruction is suspected. Please correlate with CT.
    • 2022-12-15 Small bowel obstruction is suspected. Please correlate with CT.
  • 2022-12-14 CT - abdomen
    • CC: Abd fullness for 2+ weeks, poor appetite,
    • Past History: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, hemicolectomy at TSGH on 2021-05-13.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is massive ascites and soft tissue lesions in the omentum and mesentery.
        • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • There is suggestive tumor seeding in splenic flexure colon, causing marked dilatation of the proximal colon and small intestine.
        • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
      • There are multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
      • There are two kissing poor enhancing lesions in S4/8 of the liver that are c/w liver metastases.
      • Abdominal aorta shows atherosclerosis, aneurysm 3.2 cm and mild intramural thrombus formation.
      • A calcification 7 mm in S4 liver is noted that is c/w old granuloma.
      • There are several renal stones on both kidney and the largest one measuring 0.6 cm in right middle pole.
        • There are several renal cysts on both kidney and the largest one measuring 1.1 cm in size at right upper-middle pole.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • S/P cholecystectomy.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, and spleen.
        • The IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
      • Multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space.
      • Two metastases in S4/8 of the liver.
  • 2022-12-14 KUB
    • Increased air in distended loops of small bowel over abdomen and pelvicr ,could be adhesive or mechanical ileus.
    • Abdominal ascites
    • Surgical clips over the abdomen
  • 2022-12-14 ECG
    • Sinus tachycardia
    • Possible Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-10-14 Anoscopy
    • Stool color: normal
    • Rectal mucosa: normal
    • Anal canal: abnormal
    • Impression: 2022-05-20 DRE/anoscopy: mixed morrhoids with perianal skin erosion(+)
  • 2022-10-01 CT - abdomen
    • Colon cancer s/p operation. Increased soft tissues at left abdominal cavity suspected tumor seeding.
    • A poor enhancing nodule (1.1cm) at pancreatic tail.
  • 2022-06-13 CT - abdomen
    • Very faint soft tissue nodule at left subphrenic region about 0.74cm in largest dimension.In comparison with CT dated on 2022-03-11, the lesions are stationary.
    • s/p cholecystectomy
    • s/p LAR.
  • 2022-03-21 Anoscopy
    • Hemorrhoid and anterior anal fissure
  • 2022-03-11 CT - abdomen
    • Two soft tissue nodules in LUQ omentum measuring 8 mm and 5 mm that may be post-operative change.
    • The differential diagnosis include tumor seeding but less likely.
  • 2022-02-21 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed faint hot spots in the left rib cage, and increased activity in the maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the left rib cage, maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
  • 2021-12-06 CT - abdomen
    • Colon cancer s/p operation. No evidence of tumor recurrence.
    • Wall edema of colon r/o colitis. Focal small bowel ileus.
  • 2021-08-26 CT - abdomen
    • Colon cancer s/p operation. No evidence of tumor recurrence.
  • 2021-06-10 Whole body PET scan
    • Glucose hypermetabolism in multiple abdominal bilateral paraaortic lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in some left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and in a small focal area in the upper lobe of right lung. The nature is to be determined (inflammatory process? other nature such as metastases?). Please follow up other imaging modalities for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.

[consultation]

  • 2022-12-21 Orthopedics
    • Q
      • The patient is an 63-year-old man with a history of K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, Hypertension.
      • He presented with left knee painful since yesterday, progression when movement. Suspect OA knee.
      • Follow-up knee bil. x-ray today. We need your further evaluation and management.
    • A
      • S: 63 male
      • Dx: Left knee OA, grade II
      • O
        • No open fracture
        • Intact N/V
      • Plan:
        • OPD f/u
        • Pain management with pain killers
        • RICE (Rest, Ice, Compression, and Elevation)
  • 2022-01-04 Infectious Disease
    • Q
      • The 61 y/o man has watery diarrhea per day for 2-3 weeks and went to PoJen General Hospital for colonscopy /p biopsy. Thus, he sent to TSGH for future management and D- and Sigmoid PD adenocarcinoma with invading to the visceral peritoneaum, pT4aN2b, stage IIIC at least, lymphovascular invasion (+), perineural invasion (+) (LN met 11/16 and 5/11) at least post hemicolectomy at TSGH by GS Chan DChung on May 13, 2021.
      • port-A insertion on 2021-06-09. PET was performed on 2021-06-11 which showed There was increased FDG uptake in some left supraclavicular lymph nodes (SUVmax early: 8.27, delay: 10.54), in a small focal area in the upper lobe of right lung (SUVmax early: 3.30, delay: 5.38), in bilateral pulmonary hilar lymph nodes (SUVmax early: 4.86, delay: 6.77) and in multiple abdominal bilateral paraaortic lymph nodes (SUVmax early: 7.50, delay: 13.69). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters. Radiotherapy with 4500cGy/25 fractions were done. Under the diagnosis of Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.
      • He received chemotherapy with
        • C1D1 FOLFIRI on 2021/06/11-13.
        • C1D15 Avastin plus FOLFIRI on 2021/06/25-27.
        • C2D1 Avastin plus FOLFIRI on 2021/07/12-14.
        • C2D15 Avastin plus FOLFIRI on 2021/07/27-29
        • C3D1 Avastin plus FOLFIRI on 2021/08/10-12
        • C3D15 Avastin plus FOLFIRI on 2021/08/23-25.
        • => Followed CT of abdomen on 2021/08/26 which revealed Colon cancer s/p operation. No evidence of tumor recurrence.
        • C4D1 Avastin plus FOLFIRI on 2021/09/06-09/08
        • C4D15 FOLFIRI on 2021/9/27-29.
        • C5D1 Avastin plus FOLFIRI on 2021/10/12-14.
        • C5D15 Avastin plus FOLFIRI on 2021/10/26-28.
        • C6D1 Avastin plus FOLFIRI on 2021/11/10-12.
        • C6D15 Avastin plus FOLFIRI on 2021/11/23-25
      • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
      • clostridium difficileGDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec,2021 although cultural results showed no infection signs.
      • He was admitted for scheduled chemotherapy this time, however still severe diarrhea and clostridium difficileGDH andToxin A/B, which still showed GDH and Toxin A/B all positive. we need your expertise for further management,thanks
    • A
      • The patient’s condition was as your description.
        • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
        • clostridium difficile GDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec, 2021.
      • Clostridium difficile associated diarrhea was impressed.
      • Suggestion:
        • Vancomycin 125 mg po qid is suggested for 10 days.
        • Please keep contact isolation
  • 2021-09-06 Radiation Oncology
    • A
      • A: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon, AJCC pathological staging pT4aN2b(cM0), stage IIIC at least, s/p operation.
      • P: Radiotherapy is indicated for this patient with the following indicators: D-S colon cancer, stage pT4aN2b(cM0), stage IIIC, wth visceral peritoneum invasion and tumor focal attach to the nearest circumferential margin.
        • Goal: curative
        • Treatment target and volume: primary tumor bed, peripheral, to regional lymphatic including pelvic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions.
        • The patient’s family is going to apply the details of medical records. I would like to view those including preoperative CT scan image to clarify the tumor location and then make a decision.
        • RTC: in one week

[radiotherapy]

[chemoimmunotherapy]

  • 2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • … … ..

  • 2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • … … ..

  • 2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL

==========

2023-02-24

  • There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.

    • 2023-02-23 WBC 3.44 x10^3/uL
    • 2023-02-10 WBC 2.83 *10^3/uL
    • 2023-02-03 WBC 3.09 *10^3/uL
    • 2023-01-27 WBC 4.43 *10^3/uL
    • 2023-01-15 WBC 4.05 *10^3/uL
    • 2023-01-12 WBC 5.79 *10^3/uL
    • 2022-12-29 WBC 5.29 *10^3/uL
    • 2022-12-26 WBC 7.99 *10^3/uL
  • The patient’s HbA1c levels have slowly increased and warrant attention.

    • 2023-02-20 HbA1c 6.1 %
    • 2022-12-06 HbA1c 5.8 %
    • 2022-09-05 HbA1c 5.7 %
  • Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.

  • The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.

2023-01-16

  • Based on the records, bowel movements were 2, 2, 1 over the past three days. No further diarrhea has been observed; loperamide might not be continued. (The drug has not been refilled after the original prescribed expired.)
  • Blood sugar levels remain at 90 mg/dL, they are in good control.

700174936

230223

[past history]

  • Medical history:

    • Heart: hypertension and dyslipidemia for 10+ years under medical control
    • Other medical:
      • Insomnia, but does not use sleeping pills
      • Asymptomatic gallbladder stones
  • Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)

  • Menstrual history: G0P0, Last menstrual period:2022/8/2

    • Menarche at the age of 13 years old
    • Menstrual cycle:Duration/Interval:7-14days/28days
    • Amount: moderate —> changed to menstruation 1 time per year for the past 3 years
  • Has regular Pap smear examination (most recent 2022/08/03)

[allergy]

  • NKDA         

[family history]

  • Mother had hysterectomy, but the patient doesn’t know why
  • Mother has thalasemia anemia and hypertension

[exam findings]

  • 2022-12-30 - CT - abdomen
    • History: Left ovary cancer of clear cell carcinoma s/p Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy on 2022/09/22, pT1aN0; stage IA; FIGO stage IA
    • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P hysterectomy
      • Severe fatty liver, grade 5, is noted.
      • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
      • There is a soft tissue enhancing lesion in left adrenal gland, measuring 1.3 x 0.9 cm in size, that may be adenoma. please correlate with clinical condition.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P hysterectomy
      • Severe fatty liver, grade 5, is noted.
      • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
      • Left adrenal adenoma is highly suspected. please correlate with clinical condition.
  • 2022-10-19 Gynecologic Ultrasonography
    • Suspected LT skin sub? cyst: 16mm x 11mm
    • ATH + BSO
  • 2022-09-23 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, BSO — Clear cell carcinoma
      • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy (0/15)
      • AJCC 8 th edition, Pathology stage: pT1aN0; stage IA; FIGO stage IA
    • MACROSCOPIC EXAMINATION
      • Procedure: Laparoscopic hysterectomy + BSO + BPLND
      • Specimen Size:
        • Multiple pieces, up to 7.5 x 2.2 x 0.5 cm (Lt ovary, received for frozen section), multiple pieces up to 2.5 x 2.0 x 1.5 cm (Lt ovary), 5.5 x 1.2 x 0.7 cm (Lt tube), 4.5 x 3.2 x 2.5 cm (Rt ovary), 4.5 x 1.5 x 0.9 cm (Rt tube), 12.0 x 7.0 x 5.0 cm and 100 gm (uterus)
      • Specimen Integrity
        • Right ovary: Capsule intact
        • Left ovary: Fragmented
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement: Absent
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: Cannot be assessed (about 5-6 cm in dimension)
      • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
      • Representative parts are taken for section and labeled as: F2022-00449FS and A1-A3, A4, A6 = left ovary, A5 = left tube. S2022-16185A = left iliac LNs, B = left obturator LNs, C = right iliac LNs, D = right obturator LNs, E1 = cervix, E2-E7 = uterine corpus, E8-E9 = endometrium, E10-E11 = right ovary, E12 = right fallopian tube, F1-F2 = left ovary.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Clear cell carcinoma
      • Histologic grade: High-grade
      • Implants: Not identified
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal Fluid: Not submitted
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells
        • number of lymph node examined: 2 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1a (tumor limited to one ovary)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IA
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with squamous metaplasia
        • Endometrium: Endometrial polyp with endometrial hyperplasia
        • Myometrium: Leiomyoma and adenomyosis
        • Ovary, right: Endometrosis
        • Fallopian tube, left: Unremarkable
        • Fallopian tube, right: Hydrosalpinx and hemosalpinx
  • 2022-09-22 Frozen Section
    • Ovary, left, frozen section — Malignant, clear cell carcinoma can be considered
  • 2022-09-21 ECG
    • Marked sinus bradycardia
    • Septal infarct, age undetermined
    • Nonspecific ST abnormality
  • 2022-08-20 Gynecologic Ultrasonography
    • Suspected LT ovarian mass with (papillary 24x23mm)
    • Uterine myoma
  • 2022-08-03 Mammography
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.

[surgical operation]

  • 2022-09-22
    • Surgery
      • Diagnosis: Left ovarian tumor suspected malignancy for staging surgery.    
      • Operation: Laparoscopic gynecologic oncology staging surgery (Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy)   - Finding
      • Left ovarian tumor, suspected malignancy.
      • Frozen: clear cell carcinoma
      • Uterus: irregular shape due to multiple uterine myomas with size 9x8cm, there was dense adhesion with bladder, peritoneum due to previous endometriosis surgery before, adhesiolysis was performed smoothlt.
      • LOV: 6x7x5xcm , capsule intact , smooth surface, with yellowish mucus fluid content and necrotic tissues found within the ovary .
      • ROV: 3x3x2 cm , grossly normal
      • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , about 10 ml
      • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: not seen
      • Liver: grossly normal & smooth
      • Appendix: grossly normal.
      • After the operation, check the bleeder and spray the arista on both pelvic lymph nodes lesion
      • Estimated blood loss: 300 ml
      • Blood transfusion: nil
      • Complication: nil  

[chemoimmunotherapy]

  • 2023-02-22 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-01-30 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-28 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-07 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-14 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-10-21 - paclitaxel 175mg/m2 260mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2023-02-23

  • The patient exhibited severely elevated blood pressure of 228/122 at 19:17 on 2023-02-22, which should be noted as it indicates that her blood pressure was unstable.
  • The patient’s 2023-02-22 lab results showed generally normal readings, and she is tolerating the treatment well.
  • The active prescription for the patient’s underlying conditions, including hypertension, chronic viral hepatitis B, and hypomagnesemia, has been prescribed without an issue.

2022-10-24

  • The patient has just undergone her first treatment with paclitaxel/carboplatin and her TPR and blood pressure are stable.
  • The active prescription does not present a problem.

701468007

230223

[past history] - 2023-02-22 admission note

  • The patient had no systemic diseases, including endocrine、CNS、CV
  • history of operation:
    • s/p abdominal total hysterectomy (ATH) for 20+ y/o ago
    • s/p Urethovesicopexy
    • s/p bilateral cataract
    • s/p rectal biopsy on 2023/02/01
    • s/p L’t port-A on 2023/02/15
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid):OK。
  • Regular medications or herb:no            

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[lab data]

  • 2023-02-12 HBsAg Nonreactive
  • 2023-02-12 HBsAg (Value) 0.44 S/CO
  • 2023-02-12 Anti-HBc Reactive
  • 2023-02-12 Anti-HBc-Value 7.26 S/CO
  • 2023-02-12 Anti-HCV Nonreactive
  • 2023-02-12 Anti-HCV Value 0.11 S/CO

[exam findings]

  • 2023-02-03 MRI - pelvis
    • CC: She sufferred from constipation for 2 months. This time, anal pain and anal bleeding after defecation developed recently. Digital examination: swelling anorectal region, 7 o’clock rupture.
      • 20230117 sigmoidoscopy: perianal swelling and extensive ulcerative lesion over 6-8 o’clock. Suspected anorectal ulcer
    • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position.
    • Scanning protocol:
      • Axial plane: spin echo T1WI, diffusion weighted images, Non-Fat-saturation FSE T2WI, and HASTE T2WI
      • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI,
      • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the rectum and aus, with right lateral exophytic growing measuring 4 cm in size. The cranial-caudal dimension of the rectal lesion is measured about 8 cm in length.
        • The fat plane between this mass and right levator ani muscle shows obliteration that is c/w direct invasion.
        • In addition, the rectal mass shows poterior extension to the perineum.
        • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion (T3) is highly suspected.
        • Please correlate with biopsy.
      • There are five enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w regional metastatic nodes.
        • The largest one measuring 1.3 cm.
        • In addition, There are several enlarged nodes in bilateral inguinal area that are also c/w regional metastatic nodes (N1a).
      • Others
        • There is no focal lesion in the urinary bladder and vaginal.
        • There is no evidence of ascites.
        • The visible artery and vein show unremarkable finding.
    • IMP:
      • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion is highly suspected. Please correlate with biopsy.
      • According to American Joint Committee on Cancer (AJCC) staging system, 9th edition for anal cancer: T3N1aM0, stage:IIIC
  • 2023-02-02 CT - abdomen
    • History and indication: anorectal ulcer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent tissue invasion, regional LAP and perforation. Colonic diverticula.
      • Some calcifications in bil. breasts.
      • Hyperplasia of left adrenal gland.
      • Some LNs at bil. inguinal regions.
      • S/P hysterectomy. Suspected left ovary cyst (1.8cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Addendum Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N1a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-02-02 Patho - colon biopsy
    • Anorectum, biopsy — squamous cell carcinoma, moderately differentiated
    • Section shows pieces of squamous mucosa with invasive squamous cell carcinoma.
    • The immunohistochemical stains reveal CK5/6(+), p40(+), CDX2(-), and CD56(-). The results are supportive for the diagnosis.
  • 2023-01-31 ECG
    • Sinus rhythm with Premature atrial complexes
    • Left axis deviation
    • Right bundle branch block
  • 2023-01-17 Sigmoidoscopy
    • Findings
      • 30cm to S colon, diverticulosis of S colon.
      • perianal swelling and extensive ulcerative lesion over 6~8 o’clock.
    • Diagnosis
      • anorectal ulcer, easily bleeding, pt complain better
    • Suggestion
      • repeat 1 month later.
    • Complication
      • No immediate complication
  • 2023-01-13 CXR
    • Cardiomegaly is noted.
  • 2023-01-13 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • Left axis deviation
    • Right bundle branch block
    • Abnormal ECG

[SOAP]

  • 2023-02-10 Radiation Oncology
    • CCRT is indicated but old age. CT-simulation will be arranged on 20230215. Plan to deliver 45 Gy/ 25 fx to the pelvis (including inguinal, int & ext iliac lymphatic drainage area). Then boost the anal tumor and LAPs to 54 Gy/ 30 fx.

[chemotherapy]

[assessment]

  • The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)

  • The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.

  • Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.

  • In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.

  • A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.

700348666

230221

This patient passed away at 10:19, 2022-11-03.

701470008

230221

[lab data]

2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL

2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL

2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable

2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO

[exam findings]

  • 2023-07-03 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy — Compatible with AML with partial remission at least, see description
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD117: negative for blast
        • CD34: positive for blast
        • CD61: positive for megakaryocyte
        • CD71: positive for erythroid series
        • CD68: positive for monocyte
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.2 x 0.2 x 0.2 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for sections after short decalcification.
    • MICROSCOPIC EXAMINATION
      • Hypocellularity for her age, 30%
      • M/E ratio about 1.5/1, largely normal maturation of myeloid and erythroid series
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation
      • Some scatter large nucleated cells, which IHC shows CD34(-) / CD117(+) / CD68(+/-, equivocal), maybe residual blast or erythroid precursor
      • According to all histopathologic finding, it is compatible with acute myeloid leukemia with partial remission at least. Clinical or smear correlation is needed for conclusive diagnosis due to histologic limitation. Closely follow up.
  • 2023-02-09 CXR
    • Enlargement of cardiac silhouette.
  • 2023-02-06 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with acute myeloid leukemia with maturation
    • The sections show hypercellular marrow (95%). M/E ratio = 3:1 in CD71 immunostain. The marrow space is partially replaced by a population of medium to large-sized immature cells with round to oval nucleus and prominent nucleoli.
    • IHC, increased CD34+ and or CD117+ blasts, constitue 40% of marrow cells. Most blasts are also positive for MPO and a few blasts are positive for CD68. The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-02-06 Gynecologic Ultrasonography
    • EM: 6.7mm.
  • 2023-02-02 CXR
    • Increase bilateral lung markings.

[MedRec]

  • 2023-07-06 Progression Note
    • Problem #1: Acute myeloid leukemia, 46,XX[20], status post induction chemotherapy with I3A7 on 2023/02/13-19, consolidation chemotherapy with hige dose Ara-C on 2023/04/12-15, 2023/06/02-05
      • Assessment: pending for bone marrow biopsy
    • Plan:
      • Followed bone marrow aspiration and biopsy on 2023/7/3 and pending
      • Family meeting on 2023/07/06 10:30, explained the current condition and further chemotherapy, alloPBSCT
      • closely monitor clinical condition
    • Medical team explained the current changes in the patient’s disease and future treatment direction:
      • The patient was diagnosed with Acute Myeloid Leukemia in 2023-02. Induction chemotherapy (I3A7) was given from 02/13 to 02/19. A follow-up bone marrow biopsy on 02/24 showed partial remission. Starting from 04/11/2023, the patient has been receiving consolidation treatment (High dose Ara-C) in two courses.
      • The initial white blood cell count was 100,000, indicating a poorer prognosis. The recent bone marrow biopsy during this hospitalization showed that complete remission has not yet been achieved. We discussed the subsequent treatments and the possibility of allogeneic peripheral blood stem cell transplant.
      • The patient’s sister will have HLA-ABC DR DQ typing performed for compatibility matching.
      • We explained and presented the consent form for matching from the Tzu Chi Stem Cell Registry.

[consultation]

  • 2023-02-06 Obstetrics and Gynecology
    • Q
      • This is a 29-year-old female with history of GERD. She denied systemic diseases, operation history or allergic history. She is ADL independent. This time, she suffered from abdominal distension for 1 months, accompanying with exertional dyspnea and bilateral lower limb edema for 5 days. Her dyspnea exacerbated during walking, and relieved during resting. She denied fever, chills, shortness of breath, dysuria, or abdominal pain. She visited local clinic first, and lab data revealed severe leukocytosis (92720) and anemia with HgB: 4.7. Then, she was transfered to Cardinal Tien Hospital. In order of further examination and survey, she was transfered to our ER due to leukocytosis, suspected leukemia. During ER, her vital sign showed BP:132/72, PR:123, BT:35.9 degree celsius, RR:18. Lab data showed severe leukocytosis (103.39 10^3/uL), anemia (HgB: 4.9 g/dL), thrombocytopenia (PLT: 52 10^3/uL). KUB and CXR showed negative findings. LPRBC 2U was transfused for her anemia.
      • Under the impression of anemia and abdominal distension, suspected acute leukemia, she was admitted for further hematological survey.
      • We strongely need your expertise for ceasing menstrural period due to severe thrombocytopenia (20230206 PLT: 78000/ul). Thank you very much.
    • A
      • S/O
        • SEX(+), LMP:2022/12/18 (moderate amount. irregular period, duration: 3~5 days)
        • NDKA
        • PHx: denied GYN history or family history GYN history. 2022/09 covid-19 infection.
        • Medication or hormone use: denied any hormone use before.
        • CC: for leukemia treatment.
        • PV: no lifting pain. clear discharge.
        • TVS (transvaginal ultrasound):
          • Uterus: AFV, 81X40 mm
          • EM:6.7 mm
          • ROV:27x12 mm
          • LOV:16x15 mm
      • Suggestion and plan:
        • Check pregnancy test. (Irregular menstrual cycle. )
        • Leuplin 3M 11.25 mg syringe SC ST for 1 dose
        • For long-acting Leuplin, one dose can last for three months, and at most two doses can last for six months. Patients have been informed that each dose will cost about TWD 10000 at their own expense.
        • The patient has been taught that Leuplin takes time to act, if there is still menstruation or heavy bleeding this month, oxytocin and transamin can be used (please contact obstetrics and gynecology).

[chemotherapy]

  • 2023-07-07 - [fludarabine 30mg/m2 46mg NS 500mL 30min + cytarabine 2000mg/m2 3000mg NS 500mL 4hr] D1-5 (FLAG Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-06-02 - cytarabine 3000mg/m2 4500mg NS 500mL 4hr Q12H D1-4 (HD Ara-C Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
  • 2023-04-12 - cytarabine 1500mg/m2 2190mg NS 500mL 3hr Q12H D1-4 (HD Ara-C Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
  • 2023-02-13 - idarubicin 10mg/m2 14mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 145mg NS 500mL 24hr D1-D7 (idarubicin/cytarabine 3+7 Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf

ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf

==========

2023-07-07

  • In this hospital stay, the patient’s chemotherapy regimen has been augmented with the addition of fludarabine. I prepared information sheets for the patient on fludarabine and cytarabine and brought them to the ward. I visited her around 13:20 on 2023-07-07. Both the patient and her mother were present; the patient was standing and seemed to be reaching for something, and I observed that she was in good spirits. I highlighted the key points and potential side effects on the medication sheets with a colored marker, verbally informed both of them, and asked them to let our medical team know as soon as possible if they notice any suspected adverse drug reactions. I also left them with the contact information for the medication consultation window for their future reference.
  • During the visit, the patient’s mother asked about the results of the bone marrow biopsy performed on 2023-07-03. I informed her that questions regarding the patient’s condition and treatment strategy should be addressed to the attending physician. It is up to Dr Gao to disclose this information to the patient’s family as clinically necessary.

2023-02-11

  • Dr. Wan asked how long the stability of cytarabine lasts this morning. After calling the original supplier, the manufacturer said that the physical and chemical stability can be longer, but the microbiological stability is as shown in the package insert.
  • The content of this article “An 1H NMR study of the cytarabine degradation in clinical conditions to avoid drug waste, decrease therapy costs and improve patient compliance in acute leukemia” (Anticancer Drugs. 2020;31(1):67-72. doi:10.1097/CAD.0000000000000850) is the result of using Ara-C test instead of Cytosar.

700057920

230220

  • diagnosis - 2022-11-03 discharge
    • recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery, stage IV
    • Intrahepatic bile duct carcinoma status post laparoscopic S6-7 resection on 2020/09/30. ECOG:0, stage IV
    • chronic viral hepatitis B without delta-agent
    • liver cirrhosis, HBV related. Child A
  • exam findings
    • 2022-11-14 Ascites tapping
      • 2700mL
    • 2022-11-01 PTCD (Percutaneous Transhepatic Cholangial Drainage) revision
      • Obstruction of the PTCD catheter.
      • Revision of the catheter smoothly.
    • 2022-10-26 CT - abdomen
      • History and Indication:
        • 20080128 CT: HCC in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal, MRI:HCC 4.8 cm in S7 is suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • 20201002 Liver, S6-7 resection: cholangiocarcinoma
          • pT1aNx; Stage IA at least
        • 20220330 CEA, CA199, and AFP: normal.
      • IMP:
        • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows stable disease.
        • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show stable disease.
          • Multiple metastatic nodes in the mesentery S/P C/T show partial response.
        • Carcinomatosis is highly suspected.
          • Please correlate with ascites cytology.
          • In addition, there is marked increased the volume of the ascites.
          • please correlate with clinical condition.
    • 2022-09-26 Endoscopic Retrograde CholangioPancreatography, ERCP
      • diagnosis
        • Failed to reach major papilla
        • CBD stricture s/p PTCD
        • Duodenal stenosis, proximal 2nd portion and SDA
        • Duodenitis and duodenal tumor with ulcer
      • suggestion
        • PPI
    • 2022-09-05 KUB
      • S/P PTCD catheter implantation via left lobe IHD approach and the tip located at S2/3 IHD?
      • Fecal material store in the colon. -Mild ascites is suspected. Please correlate with sonography.
    • 2022-08-24 CT - abdomen
      • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows partial response.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show partial response.
        • Multiple metastatic nodes in the mesentery show progressive disease.
      • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
    • 2022-06-15 CT - abdomen
      • One recurrent cholangiocarcinoma measuring 1.6 cm in S4 of the liver is suspected.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery S/P CT show partial response.
      • There is ascites in the abdomen and pelvis with smuddgy appearance at the perihepatic omentum area.
      • Please correlate with ascites cytology to R/O carcinomatosis?
    • 2022-05-09 Endoscopic Retrograde CholangioPancreatography, ERCP
      • Failed Cholangiography due to inablity to reach major papilla
      • CBD stricture s/p PTCD
      • Duodenal stenosis, proximal 2nd portion and SDA
      • Duodenitis and duodenal tumor with ulcers
    • 2022-04-29 Percutaneous Transhepatic Cholangiography and Drainage, PTCD
      • Dilatation of the biliary tree (by US images).
      • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
      • No procedure-related complication during the whole procedure.
    • 2022-04-28 SONO - abdomen
      • Diagnosis
        • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
        • Dilated CBD & bilateral IHD
        • Lymphadenopathy at pancreatic head area
        • Splenomegaly, moderate
        • Ascites, left retroperitoneal
      • Suggestion
        • ultrasound follow up ascites.
    • 2022-04-22 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
        • suspicious,subphrenic abscess or biloma , S7 area.
        • Prominent bilateral IHD and MPD
        • suspiciosu, Renal stone, right
        • lymphadenopathy at pancreatic head area
        • Splenomegaly, moderate
        • Ascites, left retroperitoneal
        • CBD, GB, pancreatic body masked
      • Suggestion
        • ultrasound follow up ascites.
    • 2022-04-20 Patho - lymphnode biopsy
      • Lymph node, hepatic hilum, EUS FNB — Compatible with metastatic cholangiocarcinoma
      • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Extensive tumor necrosis and moderate neutrophil infiltration are present.
      • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with metastatic cholangiocarcinoma.
    • 2022-04-20 Patho - liver biopsy needle/wedge
      • Liver, EUS FNB — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma, recurrent
      • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Tumor necrosis, hemorrhage, and neutrophil infiltration are present.
      • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with recurrent cholangiocarcinoma.
    • 2022-04-20 Endoscopic Ultrasonography, EUS
      • Diagnosis
        • Hepatic tumor, S4, s/p CH-EUS and FNB, suspect cholangiocarcinoma
        • Lymphadenopathy, hepatic hilum, s/p CH-EUS and FNB, suspect metaplastic lesion
        • Ascites
      • Suggestion
        • pursue pathological result
    • 2022-04-01 CT - abdomen
      • Three recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Please correlate with MRI.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery.
    • 2022-01-03 CT - abdomen
      • Liver tumor s/p operation with a biloma formation (3.5x7.9cm). A LN (1.5cm) at hepatic hilar region.
    • 2021-10-15 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • post partial right hepatectomy.
        • Calcified spot of liver, S4/7 area.
        • GB, pancreatic body and tail masked by gas.
        • Left hepatic lobe hypertrophy
        • Much colon gas.
      • Suggestion
        • semi-annual ultrasound follow up.
    • 2021-07-19 SONO - abdomen
      • Diagnosis
        • Liver cirrhosis
        • Status post S6/7 liver segmentectomy
        • Hepatic calcified spots
        • Fatty pancreas
      • Suggestion
        • keep follow up
    • 2021-04-30 CT - abdomen
      • History and Indication: FL + HCC + HBV , normal LFT
        • 20080128 CT: HCC in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal, MRI:HCC is highly suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • 2020/10/02 Liver, S6-7 resection: cholangiocarcinoma
          • pT1aNx; Stage IA at least
      • IMP:
        • S/P near total right hepatectomy. There is no evidence of tumor recurrence.
        • Biloma in right surgical margin shows decreasing in size to 4 x 2.2 cm.
    • 2021-02-25 Hearing Test
      • Tymp bil type A
      • ART bil WNL
      • PTA:
        • Reliability FAIR
        • Average RE 11 dB HL, LE 13 dB HL
        • bil normal to mild SNHL
      • SRT RE 10 dB HL, LE 10 dB HL
      • WDS RE 96 % at MCL, LE 96 % at MCL
    • 2021-02-03 SONO - abdomen
      • Diagnosis
        • Liver cirrohis
        • Propable post op related biloma, right lobe
        • C/w post liver segmentectomy
      • Suggestion
        • keep follow up
    • 2020-12-30 Patho - soft tissue
      • Labeled as “an erythematous nodules with heat and itching on left chest for 1 months -> suspected cutaneous metastasis of HCC or cholangiocarcinoma”, skin biopsy — marked perivascular lymphocytic inflammation.
      • IHC stains: CD3 and CD20: no predominant subpopulation. No metastatic carcinoma.
    • 2020-12-09 SONO - abdomen
      • Diagnosis
        • C/w post liver segmentectomy
        • Propable post op related bilioma,right lobe
        • Poor assessment of biliary tract and PV
        • Pancreas not shown
        • Suboptimal examination of liver due to poor echo window
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • 2020-11-09 CT - abdomen
      • Impression: Liver tumor s/p operation with a biloma formation (3.5x7.9cm). No evidence of tumor recurrence.
    • 2020-10-02 Patho - liver partial resection
      • PATHOLOGIC DIAGNOSIS:
        • Liver, S6-7, segmental hepatectomy — Intrahepatic cholangiocarcinoma
        • Pathologic Staging: pT1aNx; Stage IA at least
      • MICROSCOPIC EXAMINATION
        • Histologic Type: Intrahepatic cholangiocarcinoma
        • Histologic Grade: Poorly differentiated (G3)
        • Tumor Growth Pattern: Mass-forming
        • Tumor Necrosis: Present
        • Tumor Extension: Tumor confined to hepatic parenchyma
        • Large Vessel Invasion: Not identified
        • Small Vessel Invasion: Not identified
        • Perineural Invasion: Not identified
        • Pathologic Staging (pTNM): Stage IA at least (pT1aNx)
        • Margins
          • Parenchymal Margin: Free, 2.5 cm from closest margin
          • Hepatic Capsule: Involved by invasive carcinoma
        • Additional Pathologic Findings: None identified
        • Hepatitis (specify type): Hepatitis B
        • Ishak Modified HAI Grading: Score=2 (interphase hepatitis=0/4, confluent necrosis=0/6, focal necrosis=0/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F2 (Corresponding Metavir F2, periportal fibrosis)
        • Fatty Change: Present (<5%)
        • IHC: Hepa-1(-), Arginase-1(-), CK7(+), CK19(+), CD56(-)
    • 2020-09-21 Visceral Angiography 2 vessels
      • DSA of celiac trunk and common hepatic artery with post-angiography CTAP study via right common femoral artery puncture revealed:
        • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
        • Liver cirrhosis.
        • Patency of portal vein.
        • A hypervascular tumor at right hepatic lobe. A marginal enhancing nodule at S4 of liver r/o hemangioma. Some vascular blushes at right hepatic lobe r/o vascular shunting.
        • Post-angiography CTAP images also revealed a perfusion defect (5.9cm) at right hepatic lobe.
        • No procedure-related complication during the whole procedure.
      • IMP: Right liver tumor (5.9cm), HCC is first considered. Left liver hemangioma (1.1cm).
    • 2020-09-21 SONO - abdomen
      • Diagnosis
        • Liver tumor, nature?
        • Parenchymal liver disease
        • HCC s/p S5 resection
      • Suggestion
        • Please follow sonography in 3-6 mon
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2020-08-26 MRI - abdomen
      • History and Indication: FL + HCC + HBV , normal LFT and AFP
        • BWL 8 kg in 6 mon after exercise
        • 20080128 CT: HCCs in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal
      • Findings:
        • There is a well-defined, mild heterogeneous mass 4.8 x 3.5 cm in S7 of the liver. The main tumor shows hypointensity on T1WI, moderate hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows contrast enhancement in arterial phase and contrast washout in portal and delayed phase images.
          • The central area shows even higher intensity than the peripheral main tumor on T2WI and contrast enhancement in delayed phase images.
          • HCC is highly suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • S/P partial resection of S6 liver.
        • There are one enlarged node in hepatoduodenal ligament measuring 3 x 1.3 cm and several enlarged nodes in celiac trunk area, showing bright on DWI that may be metastatic nodes.
          • The differential diagnosis include benign reactive nodes.
    • 2020-07-28 Hearing Test
      • Reliabilty Fair
      • PTA
        • R’t: 13 dB HL
        • L’t: 11 dB HL
      • Bil WNL except L’t 8k Hz
      • Tymp
        • Bil Type A
      • ART
        • Bil WNL.
  • surgical operation
    • 2020-09-30
      • Surgery
        • S6-7 resection
        • laparoscope IOE
      • Finding
        • 5.5 x 5.0 x 5.0 cm well define tumor at S7
  • chemoimmunotherapy
    • 2022-11-22 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4370mg 46hr
    • 2022-11-02 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 725mg 2hr + fluorouracil 2400mg 4370mg 46hr
    • 2022-10-11 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
    • 2022-09-05 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
    • 2022-08-16 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr # The chemotherapy Q2W shift to Q3W due to neutropenia.
    • 2022-07-27 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
    • 2022-07-08 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
    • 2022-06-13 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2200mg 3990mg 46hr
    • 2022-05-23 - fluorouracil 225mg/m2 400mg 24hr D1-3
    • 2022-05-16 - fluorouracil 225mg/m2 400mg 24hr D1-5
    • 2022-05-10 - fluorouracil 225mg/m2 400mg 24hr D1-3
    • 2022-05-04 - fluorouracil 225mg/m2 400mg 24hr D1-3

==========

2023-02-20

  • The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay.
  • No medication reconciliation issues have been found in the patient.

2022-11-22

  • The HGB level was 7.7 g/dL on 2022-11-21, and a transfusion of LPRBC 2U is scheduled.

700545433

230220

{DLBCL}

[diagnosis] - 2022-07-31 discharge diagnosis

  • Diffuse large B-cell lymphoma, lymph nodes of multiple sites
  • Diffuse large B cell lymphoma, Non-germinal center type,multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement,Lugano stage IV,IPI score:4,PS:2
  • Hypertension
  • Type 2 diabetes mellitus without complications
  • Hyperlipidemia

[lab data]

  • 2022-07-18 Amikacin <2.5 ug/mL
  • 2022-06-02 HCV RNA-PCR Target Not Detected IU/mL
  • 2022-06-01 EB VCA IgM Negative Ratio
  • 2022-06-01 EB VCA IgM Value 0.2
  • 2022-06-01 HBsAg Nonreactive
  • 2022-06-01 HBsAg (Value) 0.67 S/CO
  • 2022-06-01 Anti-HCV Reactive
  • 2022-06-01 Anti-HCV Value 2.98 S/CO
  • 2022-06-01 Anti-HBc Nonreactive
  • 2022-06-01 Anti-HBc-Value 0.18 S/CO
  • 2022-05-30 EB VCA IgG Positive Ratio
  • 2022-05-30 EB VCA IgG Value 7.2 Ratio
  • 2022-05-30 EBNA-IgG Positive Ratio
  • 2022-05-30 EBNA-IgG Value 2.5 Ratio
  • 2022-05-30 HSV 1 IgM Negative Ratio
  • 2022-05-30 HSV 1 IgM Value 0.18 Ratio
  • 2022-05-30 HSV 2 IgM Negative Ratio
  • 2022-05-30 HSV 2 IgM Value 0.04 Ratio
  • 2022-05-27 MTBC PCR NOT DETECTED
  • 2022-05-27 MTBC PCR Value <131 CFU/ml
  • 2022-05-26 CMV IgM Nonreactive
  • 2022-05-26 CMV IgM Value 0.21 Index
  • 2022-05-26 CMV_IgG Reactive
  • 2022-05-26 CMV_IgG Value 1701.6 AU/mL
  • 2022-05-26 HIV Ab-EIA Nonreactive
  • 2022-05-26 Anti-HIV Value 0.04 S/CO

[exam findings]

  • 2023-02-15 Whole body PET scan
    • There was increased FDG uptake in soft tissue in the upper and middle abdomen (SUVmax early: 18.32, delay: 27.37), and in the right lobe of the liver (SUVmax early: 17.88, delay: 26.98). In addition, increased FDG accumulation was also noted in bilateral kidneys and colon.
    • IMPRESSION:
      • The old lesions of glucose-hypermetabolism in bilateral neck and supraclavicular lymph nodes, bilateral axillary lymph nodes, mediastinal lymph nodes, pelvic lymph nodes, bilateral inguinal lymph nodes, and in multiple focal areas in bilateral lung fields disappear or come to very faint compared with the previous study on 2022-06-02.
      • However, old lesions of glucose-hypermetabolism in the upper and middle abdomen (Deauville score 5) become more evident, and there are several new lesions of glucose-hypermetabolism in the right lobe of the liver (Deauville score 5) in this study.
      • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
      • Diffuse large B-cell lymphoma s/p treatment with dissociated response to current therapy, by this F-18 FDG PET scan.
  • 2023-02-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the sternum, and increased activity in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • A hot spot in the sternum and increased activity in the maxilla, the nature is to be determined (post-traumatic change, lymphoma or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-02-10 Patho - liver biopsy needle/wedge
    • liver, CT-guided biopsy — Diffuse large B-cell lymphoma
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Liver
      • Procedure: CT-guided biopsy
      • Tumor site: Liver
      • Histologic type: Diffuse large B-cell lymphoma
      • IHC: CD3(-), CD20(+), CK(-), and CD56(-)
  • 2023-02-01 CT - abdomen
    • History and indication: abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion. Some LNs at mesentery. A poor enhancing tumor (4.0cm) at right hepatic lobe.
      • Wall thickening of rectum.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion suspected malignancy. Liver and LNs metastases.
      • Wall thickening of rectum. Suggest coloscopy study.
  • 2023-01-30 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-01-28 KUB
    • Calcified dot(s) is found at right paravertebral region, ureter stone(s) is most likely.
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
  • 2023-01-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (39 - 13) / 39 = 66.67%
      • M-mode (Teichholz) = 66.7
    • Dilated aortic root
    • Concentric LV hypertrophy
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2023-01-26 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-01-26 KUB
    • Compression fracture of L2.
    • Stool retention in the bowel.
    • Atherosclerosis of the aorta.
  • 2023-01-18 KUB + AP & lat. LS-spine
    • Mild compression fracture of L1 vertebral body
    • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
  • 2023-01-02 CT - chest
    • Indication: malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Comparison was made with previous CT dated on 2022/09/04
      • Lungs: stationary of reticular opacities at Lt lung and a small noodule at RUL-S2 compared with CT on 2022/09/04.
        • mild paraspinal fibrosis of RLL, stable.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • mild calcified plaques of the LAD coronary artery.
        • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers. minimal calcified aortic valves.
      • Pleura:no effusion.
      • Chest wall and visible lower neck: no enlarged lymphadenopathy.
      • Visible abdominal contents:
        • stationary residual of lymphadenopathy in mesentery root compared with CT on 2022/09/14.
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no bowel wall thickening in visible colonic segments and small bowel.
    • Impression:
      • post treatment change in lung and a a RUL 3mm nodule, and minimal residual small LNs at mesentery rootm as compared with CT on 2022/09/14
  • 2022-10-03, -07-14 CXR
    • Few nodular opacity projecting in both lung show mild resolving?
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-09-14 CT - chest
    • near complete resolution of an irregular soft-tissue mass at LLL and multiple nodules in both lungs and significant regression of lymphadenopathy in both sides of diaphgram as compared with CT on 2022/05/30
  • 2022-07-29 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-07-12 KUB
    • Radiopaque spot(s) at right renal region suspected renal stone(s).
    • Radiopaque density in left paraspinal portion suspected U/3 ureter stone.
    • Degeneration and spondylosis of L-S spine.
  • 2022-07-11 CT - brain
    • Brain atrophy.
  • 2022-06-30 ECG
    • Normal sinus rhythm
    • Anteroseptal infarct, age undetermined
    • T wave abnormality, consider lateral ischemia
  • 2022-06-28 CXR
    • Few nodular opacity projecting in both lung show mild resolving?
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-06-02 Patho - lung wedge biopsy
    • Lung, side?, CT-guide biopsy —- diffuse large B cell lymphoma
    • Sections show alveolar lung tissue with infiltration of large pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), CD3(-), and CD20(+). The Ki-67 is about > 90%. The results are supportive for diffuse large B cell lymphoma.
  • 2022-06-02 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above.
    • Prominently increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma should be considered first.
    • Mildly to moderately increased FDG uptake in two focal areas in the region about left lobe of the thyroid gland. The nature is to be determined (some kind of benign or malignant thyroid lesion? lymphoma?). Please correlate with other clinical findings for further evaluation.
  • 2022-06-01 2D transthoracic echocardiography
    • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis.
    • Dilated aortic root and proximal ascending aorta (35 mm).
    • Prominent epicardial and pericardial fat.
  • 2022-05-30 CT - lung/mediastinum/pleura
    • malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and
    • distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases, suggest tissue sampling.
  • 2022-05-30 SONO - abdomen
    • mild to moderate fatty liver (suboptimal exam of liver)
    • fatty infiltration of pancreas
  • 2022-05-27 Patho - lymph node region resection
    • Labeled as “Right level Ib lymph nodes”, excision biopsy — diffuse large B cell lymphoma. Non-germinal center type.
    • IHC stains: CD3 (focal +), CD20 (diffuse +), bcl-2 (diffuse +), bcl-6 (+, > 30%), MUM-1 (+, 90%), CD15 (+), CD30 (-), CD10 (-), c-myc: (+, <10%), Ki-67: 90%.
  • 2022-05-25 CXR
    • Multiple nodular opacities over both lungs. Suggest check CT scan to rule out metastases.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-05-16 Patho - lymphnode biopsy
    • Lymph nodes, L’t neck level V, excisional biopsy — Extensive coagulative necrosis with atypical B-cell proliferation
    • The large lymph node shows extensive, ring-like coagulative necrosis, 70-80% (unlikely geographic necrosis) with some nuclear debris, ghost cells, histiocytes and a few neutrophils as well as medium or large-size atypical lymphocytes in central, non-necrotic area. No granuloma is found. Immunohistochemistry of CK(-), CD3(+, scatter), CD20 (+) at subcapsular area and (-) at central area, CD68(+, scatter) and CD30(-). The three small lymph nodes show reactive change due to normal distribution of B and T-cell. The histopathologic finding and IHC stains is inconsistent with Kikuchi lymphadenitis, but infectious lymphadenitis or malignant lymphoma can not be excluded entirely due to suboptimal specimen with extensive necrosis. However, serology analysis (EBV or others) and repeat lymph node excision is advised for further evaluation. Closely follow up.
  • 2019-09-16 Knee Bilat. standing
    • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation, more severe on right side. Osteopenia of visible bones.
  • 2019-01-26 CT - abdomen
    • Focal ileus of small and large bowel.
    • Wall thickening of gastric antrum. Distention of stomach.
  • 2019-01-24 SONO color transcranial, carotid phonoangiograph, CPA
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Adequate total VA flow volume (107 ml/min).
    • Poor bilateral temporal windows for transcranial insonation.
    • Increased RI in bilateral VA, indicating distal stenosis.
    • Increased PI in right VA, indicating distal stenosis.

[consultation]

  • 2023-02-15 Psychosomatic Medicine
    • Q
      • The 77 y/o female patient with history of DM, HTN, hyperlipidemia. Under the diagnosis of Diffuse large B cell lymphoma, Non-germinal center type, multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement, Lugano stage IV, IPI score:4, PS:2.
      • She received the C1 chemotherapy R-COP on 2022/06/08. C2 R-CHOP (Epirubicin 80mg/m2) on 2022/06/29-30. C3 R-CHOP (Epirubicin 80mg/m2) on 2022/07/29-30. C4 R-CHOP (Epirubicin 80mg/m2) on 2022/08/18-19. C5 R-CHOP (Epirubicin 80mg/m2) on 2022/9/11-12. C6 R-CHOP (Epirubicin 80mg/m2) on 2022/10/3-4.
      • The patient reported feeling very down lately, with physical discomfort and a lack of energy throughout the body. It has consulted with a psycho-oncologist who suggested a referral.
    • A
      • Psychiatric impression:
        • Acute depressive state
        • r/o adjustment recation with depressive features
        • r/o persistent depressive disorder, current major depressive episode
      • Symptoms and course:
        • This is a 77 y/o female patient admitted under the diagnosis of: Diffuse large B cell lymphoma, Non-germinal center type. We were consulted for her recent depressed mood.
        • According to the patient herself and the care-giver, since she was diagnosed of the disease about 1+ year ago, she had frequently visited the hospital with multiple treatment courses, that she developed depressed mood, preoccupied over her unfortunate, negative thinking, hopeless feelings. She claimed transient suicide ideation but not prominent without plan or attempt. When she was at home, she would try to relax herself and her mood would improve.
        • However, this admission, she suffered from greater pain, that she got more dysphoric with poor appetite, and also occaisonal sleep disturbance at night, sleepiness in the daytime.
      • Suggestion:
        • Suicide risk assessment: low to moderate: denied current ideation, without plan or attempt, care-giver(+), chronic disease
        • Provide psychoeducation for suicide prevention, and emotion catharsis, the patient and care-giver could understand
        • Brintellix (vortioxetine 10mg) 1# HS for the depressed mood
        • Arrange PSY OPD f/u
  • 2022-07-14 Infectious Disease
    • Q
      • The 77 y/o woman has diffuse large B cell lymphoma stage IV, who was admitted for neutropenic fever. Due to B/C yield Staphylococcus haemolyticus, so we need your help for antibiotic assessment. (20220714 WBC 14000/uL under GCSF 300 mcg treatment) Thanks!
    • A
      • Assessment:
        • Neuropenic fever with S. haemolyticus bacteremia
        • UTI
      • Suggestion:
        • Recommend antibiotic Rx with Targocid or Vancomycin + Amikin 500mg iv Qd
        • Check B/C from Port-A, if positive, may arrange echocardiography to rule out Infective Endocarditis (IE)
        • Monitor CRP
  • 2022-06-02 Radiation Oncology
    • Q
      • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to lung suspect a tumor, so we need your help for biopsy. Thanks!
    • A
      • This is a case of lung masses, suspected lung cancer or lymphoma. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • 2022-06-01 Gastroenterology
    • Q
      • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to postive of HCV, so we need your help. Thank you.
    • A
      • O
        • ALT 82
        • bil(t) 0.23
        • HbsAg(-)
        • anti-HbcAb(-)
        • anti-hcv ab(+)
        • abdominal echo: mild to moderate fatty liver(suboptimal exam of liver), fatty infiltration of pancreas
        • CT: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • P
        • Check HCV viral load
          • If HCV RNA is detected, check HCV genotyping, and then discuss about treatment of direct antiviral agent.
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
        • GI OPD f/u for treatment
  • 2022-06-01 Hemato-Oncology
    • Q
      • for diffuse large B cell lymphoma
      • This is a 76 y/o female patient with history of DM, HTN, hyperlipidemia. This time, she came to our hospital due to right neck mass noted for 3 months. Other painful LNs were also noted at R’t level V , L’t level V and Bil. axillary, R’t inguinal region. Neck CT was done and revealed a nodular lesion (28mm) and another small one over right submandibular region, favor enlarged nodes. Also, due to lab data when admission showed elevated WBC and CRP, infection doctor was consulted, and antibiotic with ceftriaxone and Amikacin were suggested. Blood culture was also done and grew K.p. Abd. sono was done, and there’s no liver abscess noted.
      • She received right level Ib lymph nodes excision on 20220526, and the pathology showed diffuse large B cell lymphoma. She also received lung CT due to bil. lung nodules noted by CXR. Chest CT revealed an irregular soft-tissue mass (40 mm) at LLL, multiple nodules of variable sizes throughout both lungs, extensive lymphadenopathy in para-aortic region and mesentery root. Malignant lymphoma in both sides of diaphram with lung involvement or LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases were impressed. Therefore, we need your expertise for further evaluation and management.
    • A
      • Impression:
        • Diffuse large B cell lymphoma, non-germinal center type, triple hit, IPI score:3 (age, stage, extranodal)
        • Suspected LLL cancer with lung to lung metastases
      • Suggestion:
        • Arrange LLL lung CT guide biopsy for suspected lung cancer with lung to lung meta
        • Arrange PET scan for lymphoma work up, bone marrow is indicated
        • Check CEA, SCC, HbsAg, Anti Hbc, Anti HCV
        • Arrange Port A insertion
        • Arrange 2D heart echo
  • 2022-05-26 Infectious Disease
    • Q
      • According to the blood culture on 20220525 revealed GNB. General infection can not be rule out. We request your consultation for further management.
    • A
      • A patient of DM, HTN, hyperlipidemia. High fever developed and GNB sepsis was noted. In series of patients with immune-deficient fever, infection has been identified as the cause of the fever in 60% or more of cases. In at least some cases, however, the diagnosis has been presumptive, based on a favorable clinical response to antimircobial therapy, rather than on the result of definitive tests. Infection caused by pyogenic bacteria are the most common cause of fever. The generally respond well to antibiotic therapy, whether or not the etiologic microorganism is isolated. Anti-microbiologic coverage with parenteral Rocephin 2.0 gm qd or Fortum 1.0 gm q8h +- plus AMK 500 mg qd is recommended. The antimicrobial regimen can be modified once the results of the culture and susceptibility tests are available.

[chemoimmunotherapy]

  • 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
  • 2022-07-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP, vincristine not available then)
  • 2022-06-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
  • 2022-06-08 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-COP)

701182757

230220

[exam findings]

  • 2023-02-17 SONO - chest
    • left lower lung consolidation
    • left side pleural thickening with trivial amount of pleural effusion, no thoracentesis wad done due to high risk
  • 2023-02-09, -02-02 KUB
    • Scoliosis of L-spine with convex to left side.
    • Fecal material store in the colon.
    • Calcified uterine fibroid in rihgt middle pelvis.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-02 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Scoliosis of the T-spine with convex to right side.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear and nodular opacities on right lung are noted. please correlate with clinical condition or CT.
  • 2023-01-04 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Right pleural effusion is found.
  • 2022-12-26 Lower leg RT
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
  • 2022-12-26 L-spine AP+Lat. (including sacrum)
    • S/P nasogastric tube insertion
    • scoliosis of L-spine with convex to left side
    • Ueterine fibroid is noted.
  • 2022-12-26, -12-22, -12-15, -12-12, -12-08, -12-06, -12-05, -12-03 CXR
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear infiltration on both lung are noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-11-29 CT - abdomen
    • Clinical history: 75 y/o female patient with follicular lymphoma.
    • With and without contrast enhancement CT of abdomen - whole:
      • Diffuse multiple enlarged lymph nodes in the mediastinum, bilateral neck, right axillar regions, paraaortic regions and mesentery, progression
      • Paraspinal and prevertebral soft tissue with necrosis (T9-12 levels), could be due to lymphoma post treatment.
      • Focal soft tissue in right abdominal wall.
      • There are uterine tumors, some with dense calcifications, suspected uterine myomas.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • Diffuse right pleural thickening.
    • Impression:
      • Diffuse right pleural thickening.
      • Diffuse lymphoma (from neck to chest and adomen) with progression.
      • Uterine tumors some with calcifications, suspected myomas.
  • 2022-11-29 SONO - chest
    • Right thorax: partial lung consolidation was noted; no pleural effusion
    • Left thorax: no pleural effusion.
  • 2022-11-28 CXR
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, Please correlate with CT.
  • 2022-11-08 SONO - chest
    • Right thorax: minimal amount pleural effusion; thoracocentesis was not performed.
  • 2022-11-07 CXR
    • S/P nasogastric tube insertion or S/P ventricular-peritoneal shunt insertion ?
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There is scoliosis of the T-spine with convex to right side.
    • Right pleura effusion.
  • 2022-11-04 Peripheral Vascular Test - vein, lower limbs
    • Clinical diagnosis: edema
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
      • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
      • Spontaneous signal N N N N N T T A T T
      • Respiratory changes N N N N N T T A T T
      • Cough response N N N N N T T A T T
      • Compression study N N N N N T T N N N
    • Report:
      • Right side:
        • SVC: 13.7 mmHg ; 15.1 mmHg ;
        • MVO/SVC: 100 % ; 99 % ;
        • Average MVO/SVC: 99 %
      • Left side:
        • SVC: 2.4 mmHg ; 4.5 mmHg ;
        • MVO/SVC: 100 % ; 98 % ;
        • Average MVO/SVC: 99 %
      • Thrombus at L’t CFV, SFV, PV, LSV
      • Varicose vein : None
    • Conclusion:
      • C/W acute to subacute DVT involved the left CFV, PFV, proximal SFV and proximal LSV with partial recanalization. The left middle to distal SFV, left popliteal vein and left PTV were patent with loss of respiratory change and cough response due to upstream outflow venous obstruction.
      • There was no evidence of DVT detected at right leg deep venous system.
      • The right saphenofemoral venous junction (LSV) and bilateral saphenopopliteal venous junction (SSV) were competent without venous reflux.
      • The measured MVO/SVC ratio at right leg was 99%, indicated no venous stenosis or obctruction at right iliofemoral venous system.
      • Although the measured MVO/SVC ratio at left leg was 99%, the SVC at left leg was very low, compatible with outflow venous obstruction.
  • 2022-11-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 9) / 53 = 83.02%
      • M-mode (Teichholz) = 83
    • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
    • Mild aortic root calcification with sessile atheromas.
    • Prominent epicardial fat.
  • 2022-11-02 CTA - chest
    • Indication: suspected Pulmonary embolism
    • Findings
      • Chest:
        • Pulmonary embolism at both sides of the main pulmonary artery and its branches more on right side is found.
        • Right pleural effusion is found.
        • Calcified coronary arteries is found.
        • Right pleural thickening is found and consolidation over right lower lobe is found.
        • Lymphadenopathy at right paratracheal region is found.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp: Pulmonary embolism at both sides of the pulmonary artery.
  • 2022-11-02 SONO - chest
    • pleural effusion, minimal, right
    • consolidation, RLL
  • 2022-10-31 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Abnormal QRS-T angle, consider primary T wave abnormality
  • 2022-10-31 CXR
    • Consolidation in right lung
    • Right pleural fluid
  • 2022-10-17 MRI - brain
    • Indication: consciousness disturbance suspected brain mets
    • Findings
      • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
      • A left temporal base tumor mass up to 15 mm, DDx: meningioma or lymphoma?
      • Well and heterogenous enhancement after contrast administration was noted of this tumor mass.
    • Imp:
      • Brain atrophy.
      • A left temporal base tumor mass, DDx: meningioma or lymphoma?
  • 2022-10-14 CT - abdomen
    • History and indication:
      • 20190604 PET: Lymphoma in right paraspinal retroperitoneal space
      • 20190613 CT; Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum. follicular lymphoma s/p C/T & R/T.
    • FINDINGS - Comparison: prior chest CT dated 2022/09/27.
      • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
        • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
      • Prior CT identified left middle paraspinal soft-tissue mass around the descending thoracic aorta and thickening of Rt pericardium is noted again, stationary.
      • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
      • Uterine tumors with some calcifications (up to 3.8cm) suspected myomas and fibroids.
      • Small renal cysts (up to 5mm).
      • Atherosclerosis of the aorta and coronary arteries.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, and pancreas.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion in the mesentery and omentum.
    • IMP:
      • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
        • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
      • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
  • 2022-10-03 Patho - pleural/pericardial biopsy
    • Pleura, right, decortication — high grade B-cell lymphoma (please see microdescription)
    • Specimen submitted in formalin consists of multiple tissue fragments measuring up to 7.5 x 3.2 x 0.2 cm. Representative sections are taken and labeled as A1-3.
    • Sections show fibroadipose tissue with diffuse infiltration of intermediate to large size lymphoid cells.
    • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), cMYC(+), and MUM1(-). The Ki-67 is about 70%. The results are in favor of Grade 3B follicular lymphoma or GCB type diffuse large B-cell lymphoma.
  • 2022-09-28 Cell block
    • Right pleural effusion: Suggestive of lymphoma involvement
    • 7 cc red cloudy pleural effusion
    • The smears and cell block show small to intermediate size of lymphocytes with cleaved nucleus and nucleoli. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
  • 2022-09-27 CT - chest
    • Indication: Recurrent follicular lymphoma with right lung pleural effusion
    • Findings - Comparison was made with previous CT dated on 2022/09/20
      • diffuse and marked thickening of Rt parietal and visceral pleura (nvolving hemidiaphgram) with residual loculated effusion s/p pigtail drain placement (its pigtail segment is within lung parenchyma).
      • lungs compressive Rt lung volume loss (especially RML and RLL).
        • a subpleural lobular consolidation at S6 and minimal ground-glass opacities at basal segments of LLL.
      • Mediastinum and hila: enlarged LNs the visceral space especially subcarinal space and left middle paraspinal soft-tissue mass around the descending thoracic aorta.
        • small pericardial effusion and thickening of Rt pericardium.
      • Vessels:
        • extensive calcified plaques of the LAD and LCX coronary arteries.
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Heart: normal in size of cardiac chambers.
      • Visible abdominal-pelvic contents: .
        • several small bilateral renal cysts.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node. .
        • Extensive atherosclerotic change of the abdominal aorta.
    • Impression:
      • recurrent follicular lymphoma with pleural, lung, hemidiaphgram, and descending aortic involvment, and mediastinal LAP.
      • regression of Rt pleural effusion with loculations, and malposition of pigtail drain.
  • 2022-09-26 Cell block
    • Suggestive of lymphoma involvement
    • 12 cc red cloudy right pleural effusion
    • The smears and cell block show mainly B lymphocytes with small to intermediate size of atypical lymphocytes with cleaved nucleus and nucleoli.
    • Immunocytochemistry shows CD20(+), CD3(-), Bcl-2(+), Bcl-6(+, focal) and CD10(+, focal) for lymphocytes. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
  • 2022-09-20 CT - abdomen
    • Clinical history: 75y/o female patient with Recurrent follicular lymphoma at para-spinal region, Lugano stage II. Owing to poor appetite suspected peritonal seeding related.
    • Findings
      • Diffuse lobulated tumors in the pleura and pleural effusion with collapsed right lung, progression as compare with CT study on 2022-07-22.
      • R/O bilateral renal cysts, <1cm.
      • Unremarkable change of the liver, spleen, pancreas.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • There are uterine tumors, some with dense calcifications, up to 4cm, suspected uterine myomas.
    • Impression:
      • Progression of right plueral tumors and pleural effusion, right lung collapse, could be due to recurrent lymphoma with progression.
      • Uterine tumors, suspected uterine myomas.
  • 2022-09-16 MRI - T-spine
    • Indication: recurrent follicular lymphoma with low back pain
    • Findings
      • Abnormal enhancement in T10 and T11 vertebral body (esp T10), para-aoritc soft tissue lesions, right paraspinal soft tissue lesion at T9-12 levels, left paraspinal soft tissue lesionat T6-7 levels, and intraspinal lesion causing spinal cord compression at T7-10 levels (most severe at T10), indicating metastases.
      • Right massive pleural effusion.
      • End-plate degeneraiton, disc collapse with general bulging, posterolaterla osteophytes and enlarged facets causing diffuse spinal canal stenosis and neuroforaminal narrowing at at C2-3-4-5-6-7-T1.
      • No intramedullary lesion.
    • IMP: Bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10).
  • 2022-09-16 CXR
    • Atherosclerotic change of aortic arch
    • There is scoliosis of the T-spine with convex to right side.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-09-13 Abdomen, standing (diaphragm)
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Scoliosis of L-spine with convex to left side
    • Fecal material store in the colon.
  • 2022-08-16 Whole body PET scan
    • Glucose hypermetabolism involving the upper abdominal right paraaortic area, pleura of right lower lung field, right paraspinal area and adjacent T10 spine. Recurrent lymphoma may show this picture.
    • A glucose hypermetabolic lesion in the wall of the descending aorta. The nature is to be determined (lymphoma? inflammatory process?). Please correlate with other clinical findings for further evaluation.
  • 2022-08-02 Patho - omentum biopsy
    • Pathologic diagnosis
      • Para-spinal tumor, CT-guided biopsy — Follicular lymphoma, compatible with recurrence
    • Macroscopic description
      • Operation procedure: CT-guided biopsy
      • Topology: Para-spinal tumor
      • Specimen size and number: one strip of tumor tissue measured 0.5 x 0.1 x 0.1 cm in size
    • Microscopic description
      • Histology type: follicular lymphoma
      • Histology description: B-cell lymphoma characterized by proliferative small lymphoid cells.
      • Immunohistochemistry shows CK(-), CD3(-), CD20(+), Bcl-2(+), CD10(+), Bcl-6(+), CD23(+) and Cyclin-D1(-) for tumor. According to all histopathologic findings and past history, it is compatible with recurrent follicular lymphoma.
  • 2022-07-22 CT - abdomen
    • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, mild increasing in size.
  • 2022-01-24 CT - abdomen
    • History and indication: Follicular lymphoma grade I, lymph nodes of head, face, and neck
    • Impression:
      • Stationary condition of spleen lesions.
      • Total regression of retroperitoneal tumors.
      • Mild progression of right paraspinal lesions.
  • 2021-08-09 CT - abdomen
    • Stationary condition of spleen lesions.
    • Total regression of right paraspinal and retroperitoneal tumors.
  • 2021-02-19 CT - abdomen
    • Follicular lymphoma of right paraspinal area and retroperitoneal space s/p C/T & R/T show complete response.
    • Follicular lymphoma of the spleen s/p C/T & R/T show near complete response.
  • 2020-09-07 CT - abdomen
    • Much regression of spleen lesions.
    • Total regression of right paraspinal and retroperitoneal tumors.
  • 2020-03-03 CT - abdomen
    • Much regression of spleen, right paraspinal and retroperitoneal tumors.
  • 2019-12-31 CT - abdomen
    • Much regression of spleen, right paraspinal and retroperitoneal tumors.
  • 2019-12-12 MRI - C-spine
    • Indication:
      • 72 y/o, a pt of follicular lymphoma stage II Dx in May 2019 at TaiAn Hospital, s/p definitive C/T wt R-COP or R-CHOP IV Q3W x 6 finishing in Oct 2019 and R/T (15 frac) to paraspinal tumor bed from 20191113 to 20191203 by Dr JingMin Huang.
      • 20191203: right distal hand numbness for yrs with recent deterioration; neckpain also noted; clumsiness over rigth UE with weakness / eaasily lost holding things; no night pain
    • IMP:
      • Cervical spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp C7-T1 with right HIVD and compressive myelopathy.
  • 2019-09-04 Whole body PET scan
    • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region come to significantly less prominent compared with the previous study on 2019/06/04, indicating partial response to current therapy.
    • Mild and symmetric glucose hypermetabolism in bilateral pulmonary hilar regions, probably inflammatory process or physiological uptake of FDG.
  • 2019-06-13 CT - abdomen
    • Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum.
  • 2019-06-04 Whole body PET scan
    • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region, compatible with malignancy such as lymphoma. Please correlate with other clinical findings for further evaluation.
    • Mild and symmetric glucose hypermetabolism in bilateral pulmonary regions. Inflammatory process is more likely.

[consultation]

  • 2022-11-17 Rehabilitation
    • A
      • Assessment
        • Follicular lymphoma, stage II s/p chemotherapy
        • Pleural effusion in other conditions classified elsewhere
        • Shortness of breath
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2022-11-04 Cardiology
    • Q
      • Consultation for management of pulmonary embolism.
      • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II, s/p definitive C/T wt R-COP or R-CHOP regimen finishing in Oct 2019 & R/T (15 fr) to paraspinal tumor bed completed in Dec 2019. This time, she was admitted due to dyspnea for 3 days. She appeared in general weakness and fatigue.
        • CXR done in ER : right-sided pleural effusion; however, chest echo showed only minimal fluid; therefore, tapping was not done.
        • PE : bilateral coarse breathing sound, swollen and cold left lower limb. SpO2 was able to be maintined by nasal cannula 3L for now.
        • Lab data : leukocytosis with neutrophilic predominance
        • WBC: 19.4 K
        • Neutrophil: 90%
        • D-dimer: >10000
        • NT-proBNP: 1896
        • Chest CTA was done on 20221102, which showed pulmonary embolim.
      • We have started 3 days of SC enoxaparin from 11/3, and have arranged lower limb Doppler sonography and cardiac echo. We need your expertise for this patient’s pulmonary embolism management.
    • A
      • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II,
      • This patient suffered from lobulated pleural effusion, s/p VATS decortication + close drainage. at 2022/09. According to this patient, she suffered rom dyspnea and also ntoed to have left lower limb swelling for 1~2 months. Currently, her left lower limb showed no obvious erythema or swelling or edema, however, the diameter was obvious larger than right side. She had history of cancer and also in semi-bedridden status.
        • Chest CT: right side pulmonary embolis, possible some small pulmonary embolism at left upper lobe branch, no RA dilatation
      • Impression:
        • compatible with pulmoanry embolism, beween submasive(trop-I) to low risk, suspected left chronic DVT related
      • Suggestion:
        • agree with Clexane Q12H use, ( BW 47kg, Creatine 1.10)
          • May transition to NOAC after 1 week of clexane injection
          • e.g. Apixaban 5mg 1# BID or Edoxaban 60mg 1# QD or Rivaroxaban 15mg 1# BID (EINSTEIN–PE study, higher dose and may go with higher bleeding risk in this patient)
        • Due to left lower limb swelling was noted, but clinical condition not favor acute DVT, may consider chronic DVT or may-thurner syndrome or retroperitoneal fibrosis
          • => please arrange lower limb echo (for DVT survey) and echocardiography (for pulmonary embolism PEPSI score)
        • This patinet had higher risk for recurrence (bed-ridden / cancer) and may consider long term NOAC use
          • If other cause was worry, may consider search for autoimmune and coagulation profile ( but might not change clinical decision)
          • => protein C/ protein S, anti-phospholipid antibody syndrome profile, C3,C4, lupus anticoagulant
  • 2022-10-18 Radiation Oncology
    • A
      • S: For radiotherapy due to high grade follicular lymphoma with brain metastasis.
        • PI: The patient suffered from change of personality during admission. Brain MRI (2022-10-17) showed a left temporal base tumor mass, suspicious meningioma or lymphoma? For radiotherapy.
      • A: Follicular lymphoma of the spleen, right paraspinal region and retroperitoneum, stage II, s/p chemotherapy, with partial response, s/p radiotherapy, with tumor progression including brain metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis.
        • Goal: palliation
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 1400cGy/7 fractions of the whole brain, and 3000cGy/15 fractions of the metastatic brain tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy was already started at 1330, 2022-10-18.
  • 2022-10-06 Infectious Disease
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to rectal swab showed VRB, so we need your management.
    • A
      • Hx review as mentioned above and Lab data check
      • Suggestion:
        • May stop Targocid, shift to zyvox for this immunocompromised pt with increasing CRP
        • repeat B/C, monitor CRP
  • 2022-10-05 Psychosomatic medicine
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to several delirum with aggressive behavior, so we need your management. Thanks!
    • A
      • Psychiatric impression:
        • Acute agitated state
          • suspected adjustment reaction
          • suspected acute delirium
          • suspected dementia with BPSD
        • Depressive disorder
      • Symptoms and course:
        • This is a 75 y/o female patient with underlying lymphoma with right pleural effusion admitted for palliative C/T s/p 20220930 VATS decortication, and was just tranferred out from ICU at 20221005 afternoon. According to the patient, her family and side information collected:
        • Upon visit, she showed clear consciousness, alert, but very guarded and defensive attitude, irritable mood, angry, hostile attitude towards the medical team and her family. Speech were rather coherant and relevant, no obvious psychosis were noted currently.
        • Orientation:
      • Suggestion:
        • Anxicam 0.5amp IM/ Bini-U 0.5amp IM PRNQ6H if severe agitation
        • Add Utapine 1# HS, and give utapine 1# PRNHS if still irritable and sleep disturbance. Keep the xanax 1# BID for anxious mood.
        • Close monitor the vital signs, respiratory patterns after the PRN injection and medication, regularly follow up EKG
        • Further survey and treat her possible physical condition: infection, pain, urine retention…
        • Acute intervention, suicide risk assessment: moderate: denied past suicide idea or attempt; fair family support and accompany, but now in great distress and anger, impulsive
        • Suicide prevention is adviced.
  • 2022-09-29 Thoracic Surgery
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma, least stage III. Due to right pleural effusion with loculations, so we need help for chest tube insertion assessment. Thanks!
    • A
      • I have visited the patient and reviwed the images. I will arrange right VATS decortication this week. Thanks for your consultation!!
  • 2022-09-17 Neurosurgery
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10). We need your help for surgycal intervention. Thanks!
    • A
      • suggest medication treatment for the recurrent follicular lymphoma with bony metastasis first.

[chemotherapy]

  • 2022-11-30 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + bendamustine 70mg/m2 100mg NS 250mL 90min D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO

==========

2023-02-20

[tube feeding]

  • Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.

  • OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.

  • OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.

2022-10-06

[drug interaction]

  • Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).

  • There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.

700143756

230214

[diagnosis] - 2023-01-16 admission note

  • Synchronous cancer in the cecum and rectosigmoid colon, cT4aN2aM0, stage IIIC with partial obstruction and reginal lymph node metastasis s/p chemotherapy with FOLFOX from 2022/10/24 and status post robotic low anterior resection on 2022/12/20
  • Malignant neoplasm of sigmoid colon
  • Chronic viral hepatitis B without delta-agent
  • Hypokalemia
  • Constipation, unspecified
  • Cachexia
  • Insomnia, unspecified
  • Anemia due to antineoplastic chemotherapy

[past history]

  • Denied history of Hypertension, DM, asthma, cancer.
  • Denied any operation, accident and other medical history.                    

[allergy]

  • NKDA                     

[family history]

  • Father: colon cancer.
  • Mother: brain cancer.

[lab data]

  • 2022-08-23 Anti-HBc Reactive
  • 2022-08-23 Anti-HBc-Value 7.67 S/CO
  • 2022-08-23 Anti-HBs 1.00 mIU/mL
  • 2022-08-23 HBsAg Reactive
  • 2022-08-23 HBsAg Value 23.83 IU/mL

[exam findings]

  • 2023-01-03 CXR
    • staple line and hazy areas of increased opacity over Lt upper lung zone due to post op change
    • marginal spurs of multiple vertebral bodies due to spondylosis.
  • 2022-12-22 CXR
    • S/P Port-A infusion catheter insertion.
    • Right subphrenic air.
    • Presence of ileus.
    • S/P left side chest tube insertion.
    • S/P operation.
    • Right subcutaneous emphysema.
  • 2022-12-20 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, robotic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p CCRT
      • Resection margins: circumferential: involved
      • Lymph node, mesocolic, dissection —- Negative for malignancy (0/15)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: ypStage IIB, ypT4aN0(if cM0)
      • F2022-00614 Lung, LUL, wedge resection —- Negative for malignancy
    • Gross Description:
      • Operation procedure: robotic low anterior resection
      • Specimen site: rectum
      • Specimen size: 8.8 cm in length
      • Tumor size: 4.1 cm in length, annularly ulcerated
      • Tumor location: 2.7 cm and 2.0 cm away from the two resection margins, respectively
      • Depth of invasion grossly: visceral peritoneum
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as: A1: colon, non-tumor; A2-6: tumor; A7-10: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
      • F2022-00614 - The specimen submitted in fresh consists of a piece of lung tissue, measuring 9.3 x 2.0 x 1.4 cm and weighing 8g. On cutting, a fibrotic and calcified nodule measuring 0.5 x 0.4 x 0.3 cm is seen and 0.5 cm away from the resection margin. The parenchyma elsewhere is congested. The nodule is all for section in a cassette for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung, near nodule; X3-4: lung.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 0/15
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): y (posttreatment)
          • Primary Tumor (pT): pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
      • Tumor regression grading S/P CCRT: Modified Ryan scheme: Tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
      • F2022-00614 - Sections show lung with a calcified and fibrotic nodule. No malignancy is seen.
      • Addendum: The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-12-19 CXR
    • Ground glass opacity in left lung.
  • 2022-12-19 Frozen Section
    • Preliminary diagnosis: Lung, LUL, biopsy — Calcified fibrotic nodule
  • 2022-12-19 ECG
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
  • 2022-11-29, -11-24 KUB
    • S/P intrauterine contraceptive device retention over the pelvis
    • Fecal material store in the colon.
  • 2022-11-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 19) / 92 = 79.35%
      • M-mode (Teichholz) = 79
    • Indeterminated LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Suspected bicuspid aortic valve with mild to moderate aortic stenosis (AVA= 1.45 cm2 by Doppler method); mild AR; mild MR; mild TR and mild PR.
    • Dilated aortic root and proximal ascending aorta ( 34 mm) with mild calcification.
  • 2022-11-22 CXR
    • Solitary pulmonary nodule at LLL.
  • 2022-11-22 CT - abdomen
    • History and indication: A case of RS cancer s/p CCRT
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
      • Wall thickening of cecum.
      • Small liver and renal cysts.
      • Atherosclerosis of aorta, iliac arteries.
      • An IUD in the pelvic cavity.
    • IMP:
      • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
      • Wall thickening of cecum.
  • 2022-11-22 Colonoscopy
    • Rectosigmoid cancer partial obstruction s/p CCRT
    • The scope can’t pass through due to lumen narrowing
  • 2022-10-17 Bronchodilator Test
    • Rectosigmoid cancer partial obstruction s/p CCRT
    • The scope can’t pass through due to lumen narrowing
  • 2022-08-30 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-29 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Nonspecific ST and T wave abnormality
  • 2022-08-29 CXR
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-17 CT - abdomen
    • History: 76 y/o female
      • 20220726 FOBT positive at Far Eastern Polyclinic of Far Eastern Medical Foundation
      • 20220810 colonoscopy: An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion.
      • 20220816 pathological result: adenocarcinoma
    • Indication: Sigmoid colon cancer for staging
    • Findings:
      • There is segmental lobulated wall thickening measuring 6 cm in length and 1.8 cm in the maximal wall thickness at the rectal-sigmoid colon with irregular contour and lumen narrowing that is c/w adenocarcinoma (T4a) of the rectal-sigmoid colon with partial obstruction.
        • The fat plane between sigmoid colon lesion and the uterine cervix area shows obliteration that may be tumor invasion or attachment? Please correlate with MRI.
        • In addition, There are four enlarged nodes in left perirectal space that may be metastatic nodes (N2a).
      • Another lobulated soft tissue mass-like lesion in the cecum and proximal ascending colon is suspected.
        • Please correlate with colonoscopy to R/O Synchronous cancer.
      • There is a well-defined poor enhancing lesion 6 mm at S8 dome of the liver that may be cyst?
        • The differential diagnosis include metastasis?
        • However, it is too small to characterize. Follow up is indicated.
      • There is a well-defined ovoid-shaped poor enhancing lesion at right inguinal area, measuring 2.3 x 1.3 cm in size and 5HU in CT density.
        • Benign reactive node or cystic lesion is highly suspected. Please correlate with sonography.
      • There is a small nodule 4 mm at LUL of the lung.
        • Follow up is indicated.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-08-11 Patho - colon biopsy
    • DIAGNOSIS: Intestine, large, RS colon, 10-15 cm from anal verge, biopsy — adenocarcinoma
    • Description: The specimen submitted consists of 4 pieces of tissues measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • NOTE: IHC stain for MSI will be followed.
  • 2022-08-10 Colonoscopy
    • Findings
      • Using Olympus CF-H260AL, endoscopic examination of rectum and colon was done and the scope is placed up to the level of RS junction. An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion. Bx x 4 done. Internal hemorroid is noticed.
      • Internal hemorrhoid was noted.
    • Diagnosis
      • Colon cancer, RS junction s/p Bx
      • Internal hemorrhoid
      • Incomplete CFS exam

[consultation]

  • 2022-11-25 Thoracic Surgery
    • Q
      • This is a 76 year-old woman who denied having any history. According the patient, she suffered from mucous stools was pink like, abdomen flatulence, and difficult defecation since half year ago. And she came to the local clinic (Far Eastern Polyclinic), the fecal occult blood test positive noticed, so referred to our GI OPD for further assessment.
      • Colonscopy (2022/08/10) showed: 1. Colon cancer, RS junction s/p Bx. 2. Internal hemorrhoid. Abdomen CT showed: 1. Adenocarcinoma of the sigmoid colon with suspicious uterine cervix invasion is suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a(or4b)N2aM0, stage:IIIC. 2. Synchronous cancer in the cecum and proximal ascending colon is suspected on 2022/08/17. The RS colon biopsy — adenocarcinoma.
      • The radiotherapy starts from 2022/08/26, RT finished on 2022/10/12. CCRT with 5-FU (Covorin 20mg/m2, 5-Fu 225mg/m2) QW, (C1) on 2022/9/1-2022/9/2, 2022/9/5-2022/9/7, 2022/09/22-2022/09/23, 2022/09/26-2022/09/28. Chemotherapy with FOLFOX (Oxalip 85mg/m2, Covorin 400mg/m2, 5-Fu 400mg/m2、5-Fu 2400mg/m2) was given on 2022/10/24(C1D1), 2022/11/07(C1D15). Surgery will be arranged on 20221207 or later.
      • Due to CT image (2022/11/22) showed some nodules in bil. lungs, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • LUL nodule was noted. I will arrange VATS LUL wedge resection.

[surgical operation]

  • 2022-12-19
    • Surgery
      • Robotic low anterior resection        
    • Finding
      • Advanced rectal cancer s/p CCRT with anterior pelvic peritoneal invasion
  • 2022-12-19
    • Surgery
      • VATS LUL wedge resection.
    • Finding
      • One small nodule was noted over LUL, size about 0.5cm in diameter.
      • Frozen section: benign lesion.
      • One 20 Fr. straight chest tube was inserted via left 6th ICS.

[radiotherapy]

  • 2022-08-26 ~ 2022-10-06 - 5040cGy/28 fractions (15 MV photon) to rectosigmoid tumor, LAPs and cecal tumor.

[assessment]

  • 2023-12-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (w/o 5-FU bolus)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-16 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-07 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-10-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-26 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
  • 2022-09-22 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2
  • 2022-09-05 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
  • 2022-09-01 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-2 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2

==========

2023-02-14

  • A leukocytopenia event was observed (2023-02-02 WBC 1.86K/uL, Neutrophil 42% => ANC 780/uL) and the previously scheduled chemotherapy was cancelled on that day. FOLFOX is being administered without a 5-FU bolus this time. It is important to monitor the patient’s WBC count to determine whether leukocytopenia recurs.

2023-01-17

  • Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.

  • As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:

    • cetirizine, 10mg once daily
    • levocetirizine, 5mg once daily
    • fexofenadine, 180mg once daily
    • loratadine, 10mg once daily
    • desloratadine, 5mg once daily

2022-09-26

  • The CT of the abdomen on 2022-08-17 revealed possible synchronous cancer (rectal-sigmoid colon, cecum, and proximal ascending colon), a liver S8 dome lesion, and a LUL nodule.
  • Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051920/ ). Pathology (2022-08-11) IHC MSI results (for the rectal-sigmoid colon specimen) are not yet available.

701334097

230214

{not completed}

[exam findings]

  • 2023-02-08, -02-05, -01-31 CXR

    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of right and left costal-phrenic angle S/P pigtail catheter implantation at right CP angle?
    • 2023-02-08 - Patchy consolidation of both lung zone are noted. please correlate with clinical condition to R/O Bronchopneumonia.
    • 2023-02-05 - Linear infiltration over both lung zone are noted. please correlate with clinical condition.
    • 2023-01-31 - Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-02-05 CT - brain

    • Brain atrophy
  • 2023-02-03 MRI - brain

    • No evidence of intracranial lesion.
  • 2023-02-03 Electroencephalography, EEG

    • This is an abnormal EEG suspecting bilateral central epileptogenic activities intermittent diffuse slow waves at bilateral central and temporal area
    • A few sharpy contour waves or spikes over bilateral central area.
    • Please correlate clinially
  • 2023-02-03 Peripheral Vascular Test - vein, lower limbs

    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Bilateral long saphneous vein engorgement (from thigh to leg), left side more severe; connecting to bilateral engorged posterior tibial veins by perforator veins at leg level
    • 2022-01-06 Patho - colon segmental resection for tumor
      • pathology diagnosis
        • Rectum, Hartmann’s operation – Adenocarcinoma, moderately differentiated
        • Resection margins, Hartmann’s operation – Free of carcinoma
        • Lymph nodes, mesocolorectal, Hartmann’s operation — Metastatic adenocarcinoma (1/12)
        • Specime labeled pelvic tumor margin, biopsy — Necrosis and granulation tissue and free of carcinoma
        • T-colon colostomy, closure of colostomy — Free of carcinoma
        • Pathology stage: ypT3N1a(cM0); Stage IIIB
      • microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Perirectal soft tissue
        • Angiolymphatic invasion: Not identified
        • Perineural invasion: Present
        • Tumor cell budding: Intermediate
        • Circumferential (radial) margin of rectum: Uninvolved, 2 mm from the margin
        • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (1/12)
        • Extranodal involvement: Absent
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • Primary Tumor (pT): ypT3 (Tumor invades pericolorectal tissues)
          • Regional Lymph Nodes (pN): ypN1a (one regional lymph node positive)
          • Distant Metastasis (pM): cM0
        • Type of polyp in which invasive carcinoma arose: Not identified
        • Additional pathologic findings: None identified
        • Tumor regression grading S/P CCRT: Partial response (score 2)
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        • Specime labeled pelvic tumor margin: Necrosis and granulation tissue, and free of carcinoma
        • T-colon colostomy: Free of carcinoma
    • 2021-12-28 CT - abdomen, pelvis
      • Rectosigmoid colon cancer, size decreased.
      • Decreased size of pericolic lymph nodes.
      • Status post T-colostomy.
      • Right hydronephrosis and hydroureter.
      • Tiny subpleural nodules (<0.5cm) at basal LLL. Suggest close follow up.
    • 2021-12-28 Colonoscopy
      • compatible with colon cancer, 8cm AAV, with near lumen obstruction.
    • 2021-09-16 CT - abdomen, pelvis
      • Imaging stage: T3N2aM0, stage IIIB
  • lab data

    • 2022-02-24
      • All RAS mutation not detected
      • BRAF mutation not detected
  • surgical operation

    • 2022-01-05
      • surgery
        • Hartmann’s operation and closure of T-loop colostomy
      • finding
        • Advanced rectal cancer obstruction s/p CCRT and the tumor was firmly fixed to the pelvic cavity , clinically can’t be resected completely
    • 2021-09-17
      • surgery
        • T loop colostomy        
      • finding
        • Rectal cancer with obstruction, cT3N2aM0 stage IIIB
        • RUQ stoma with stent
  • radiotherapy

    • 2021-09-28 ~ 2021-11-04 - pelvis: 45 Gy/ 25 fx. R-S colon tumor and LAPs: 50.4 Gy/ 28 fx
  • chemoimmunotherapy

    • 2022-02-22 ~ undergoing - FOLFOX plus bevacizumab
    • 2021-11-29 ~ 2022-02-07 - FOLFOX
    • 2021-10-04 ~ 2021-11-01 - 5-Fu + LV (CCRT)

==========

2023-02-06

  • 2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)

  • 2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.

  • If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.

    • Depakine (valproic acid) is available in tabet, oral solution and injection forms.
    • Carbamazepine might cause hyponatremia, which might be a desired side effect to mitigate the patient’s hypernatremia (2023-02-05 Na 152 mmol/L).

2023-01-30

[compatible solutions to mitigate hypernatremia that do not rely on saline]

Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.

  • Benamine (diphenhydramine hydrocholoride)
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV compatible
  • Flucon (fluconazole)
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV not tested
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not tested
  • Furosemide
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV compatible
  • Metronidazole
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV not tested
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not tested

Use potassium supplements if necessary

  • Potassium phosphates
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not compatible

2022-04-08

  • Having been firmly embedded in the pelvic cavity, the tumor could not be surgically resected fully (2022-01-05).
  • The patient receives FOLFOX since 2021-11-29 (plus bevacizumab since 2022-02-22) s/p T loop colostomy (2021-09-17) and CCRT (late Sep to early Nov 2021).
  • According to laboratory data reported on 2022-04-06, there were no obvious abnormalities; however, elevations in ALT (60 U/L) and AST (64 U/L) should be addressed, as these two readings had been normal prior to the this last examination.
  • As metoclopramide is one of the potentially hepatotoxic drugs, some silymarin as supplementation might be an optional add-on to mitigate the potential hepatotoxicity.

701277175

230213

  • diagnosis - 20230105 admission note
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast invasive carcinoma with left axillary LN enlargement and bone metastasis, ER (+), PR (-), Her2 (+), stage IV, PS 1
    • Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
    • Secondary malignant neoplasm of bone
  • exam finding
    • 2022-10-17 CT - chest
      • Indication: left breast invasive carcinoma with left axillary LN enlargement and BONE Metases ER (+), PR (-), Her2 (+), stage IV, PS 1
      • MDCT (128 256-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows: (Comparison was made with previous CT dated on 20220702)
        • Lungs: s/p RUL operative with septal line and surrounding opacity along the interalobar fissures, and septal thickening and subpleural edema along minor fissure. septal line and septal thickening at RML too.
          • there is subpleural and reticulation at basal segments of RLL.
      • Impression:
        • post op change in RUL and RML, in regression as compared with previous CT on 20220702.
        • suspect early fibrosis in RLL.
    • 2022-07-05 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/02/11, no prominent change is noted in the previous faint hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2022-07-04 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A(minimal)
        • Superficial gastritis, body, s/p CLO test
        • Gastric erosions, antrum
        • Gastric polyps, fundus and AW site of high body, r/o fundic gland polyps
        • Duodenal shallow ulcer, bulb, AW site
      • Suggestion
        • Pursue CLO test result
    • 2022-07-02 CT - chest
      • S/P mastectomy at left side
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA
      • post op. change over right upper lobe
    • 2022-06-20 Abdomen - standing (diaphragm)
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • S/P Mastectomy, left.
    • 2022-06-14 MTBC (Mycobacterium tuberculosis complex) PCR
      • Undetectable
    • 2022-05-30, -05-27 CXR
      • Port-A catheter inserted into RA via right subclavian vein.
      • s/p right chest tube in place, its tip directed superiorly projecting over 5th rib
      • extensive hazy areas of increased opacity over Rt upper lung zone
    • 2022-05-27 Patho - lung wedge biopsy
      • DIAGNOSIS:
        • A: Lung, RML, wedge resection — organizing pneumonia
        • B: Lymph node, right, group 7, dissection — negative for malignancy (0/1)
        • C: Lymph node, right, group 9, dissection — negative for malignancy (0/1)
        • D: Lymph node, right, group 11, dissection — negative for malignancy (0/3)
        • E: Lymph node, right, group 12, dissection — negative for malignancy (0/1)
        • F2022-00248: Lung, RUL, segmentectomy — Non-necrotizing granulomatous inflammation with organizing pneumonia
    • 2022-05-26 Pulmonary Flow Volume Loop
      • Normal ventilation
    • 2022-04-22 CT - lung/mediastinum/pleura
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/P mastectomy at left side.
          • Spiculated nodule at right upper lobe up to 1.9cm in largest dimension is found. Another fissural based lesion at right middle lobe up to 1.4cm in largest dimension. In comparison with CT dated on 2021-12-17, the lesions are new. Suggest correlate with PET or other exam.
          • No evidence of bilateral pleural effusion.
          • S/p port-A placement with its tip at Superior vena cava.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • Non-specific bowel gas at abdominal cavity is found.
        • Imp:
          • S/P mastectomy at left side.
          • New spiculated nodule at right upper lobe and right middle lobe, the nature of the lesions should be further characterized or closely follow up. (mets is less likely but primary tumor or inflammation cannot be excluded.)
    • 2022-02-11 Tc-99m MDP whole body bone scan - In comparison with the previous study on 20210924, no prominent change is noted in the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition. - Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2022-01-20 Patho - breast simple/partial mastectomy
      • Breast, left, simple mastectomy (s/p chemotherapy) — No residual tumor
      • Pathology stage: ypT0N0(if cM0)
    • 2022-01-19 Lymphoscintigraphy
      • No sentinel lymph node in the left axillary region or left ant. chest wall is delineated throughout the whole study.
    • 2022-01-11 SONO - breast
      • Clinical left breast s/p C/T.
      • Right breast cysts and fibroadenomas. Suggest follow up.
      • BIRADS 6 - proven malignancy
    • 2021-12-17 CT - chest
      • No evidence of recurrent/residual tumor at both sides of the breast and other region.
    • 2021-09-24 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20210427, the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones are less evident. Bone metastases with some resolution may show this picture. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the maxilla in stationary status. Dental problem and/or sinusitis may show this picture.
    • 2021-09-06 CT - chest
      • resolution of Lt breast tumor and metastatic axillary and supraclavicular lymphadenopathy as compared with CT on 20210423.
      • minimal paraspinal fibrosis in RLL of lung.
    • 2021-04-30 CT - brain
      • No intracranial lesion based on this study.
    • 2021-04-27 Tc-99m MDP whole body bone scan
      • Multiple hot spots in the skull, anterior aspect of bilateral rib cages and bilateral iliac bones. Bone metastases should be watched out if no definite traumatic event is noted. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2021-04-26 Patho - lymphnode biopsy
      • Lymph node, left axilla, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using block S21-6478): ER (+, strong intensity, 70%), PR(-), Her2/neu: positive(score=3+), Ki-67(50%), p53 (<5%).
      • Section shows fragments of tissue with irregular neoplastic ducts infiltration.
    • 2021-04-26 Patho - breast biopsy
      • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using block S21-6477): ER (+, strong intensity, 70%), PR(+, weak intensity,5%), Her2/neu: positive(score=3+), Ki-67(80%), p53 (10%).
      • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • 2021-04-26 SONO - breast
      • Left breast tumors with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
      • BI-RADS5
    • 2021-04-23 CT - nect
      • Suspect left breast tumor with left axillary lymphadenopathy. Several small lymph nodes at left supraclavicular region.
      • Suggest further breast ultrasound correlation and tissue proof if needed.
  • surgical operation
    • 2022-01-19 Simple mastectomy and SLNB (Sentinel Lymph Node Biopsy)
      • No palpable and visible tumor over L`t breast UOQ.
      • Sentinel nodes biopsy was done
      • Simple mastectomy was done.
      • L’t big toe nail bed redness & loosen wit hpus discharge.
  • chemoimmunotherapy
    • 2023-01-05 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-10-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-09-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-08-22 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-07-25 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-06-20 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-04-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-04-01 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 130mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-03-10 - docetaxel 75mg/m2 120mg 2hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-02-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-12-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-02 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-10-05 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2021-07-29 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-02 - trastuzumab 600mg SC 5min D1 + pertuzumab 840mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2021-06-01 - docetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2021-05-05 - docetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg
  • medication
    • Xgeva (denosumab) CXGEV01
      • 2022-09-01 120mg Q1M SC OPD
      • 2022-06-20 120mg ST SC IPD 2022-06-19
      • 2022-05-06 120mg Q1M SC OPD
      • 2022-04-01 120mg ST SC IPD 2022-03-31
      • 2022-02-25 120mg Q1M SC OPD
      • 2022-01-06 120mg Q1M SC OPD
      • 2021-12-02 120mg Q1M SC OPD

==========

2023-02-13

WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.

2023-01-06

  • CT scan results from 2022-10-17 and bone scan results from 2022-07-05 indicate that the disease has remained non-progressive, indicating that the current regimen is still effective.
  • The lab results for 2023-01-05 were normal, and the vital signs during this stay in the hospital were stable.

2022-04-28

  • The patient was diagnosed with hormone receptor and Her2 positive breast cancer with bone mets. Mastectomy with SLNB was performed on 2022-01-19. Her chemoimmunotherapy with docetaxel began in May 2021, then trastuzumab and pertuzumab were added since July 2021.
  • She also received three denosumab injections for the bone mets on 2021-12-02, 2022-01-06, and 2022-02-25. Tc-99m MDP scan on 2022-04-22 showed that bone mets were stable.
  • The lab results of 2022-04-27 revealed no noticeable abnormalities. No issue with current prescription.

700380439

230210

[diagnosis] - 2022-12-02 admission note

  • Malignant neoplasm of lower third of esophagus
  • Bacteremia
  • Other specified bacterial agents as the cause of diseases classified elsewhere
  • Gastro-esophageal reflux disease with esophagitis
  • Secondary malignant neoplasm of other specified sites
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Urinary tract infection, site not specified
  • Enterococcus as the cause of diseases classified elsewhere
  • Cardiomegaly
  • Rheumatic disorders of both mitral and tricuspid valves
  • Gastritis, unspecified, without bleeding
  • Pneumonia due to Pseudomonas

[past history]

  • denied systemic diseases
  • hyperthyroidism years ago? without follow up and medicine
  • SCC of esophagus of middle to lower third esophagus with gastric involvement, ycT3N1M1, stage IVB.   

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-10 CT - abdomen
    • History: esophageal cancer S/P C/T
      • 20210118 chest CT:interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is newly-developed massive ascites and omentum cake that is c/w carcinomatosis.
        • Please correlate with ascites cytology.
        • In addition, There are newly-developed ill-defined poor enhancing masses on both hepatic lobes that are c/w liver metastases.
      • Prior CT identified multiple lung metastases are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified regional metastatic node in right lower para-esophageal mediastinum 2 cm is noted again, mild increasing in size to 2.5 cm.
      • There are several renal cysts on both kidney and the largest one measuring 2 cm in size at right umiddle pole.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery.
    • Impression:
      • Carcinomatosis and liver metastases (newly-developed).
      • Multiple lung metastases show progressive disease.
      • Metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space show progressive disease.
      • Metastatic regional node shows progressive disease.
  • 2023-01-18 CT - chest
    • Indication: esophageal cancer, S/P chemotherpaycheck chest C.T.
    • MDCT (128-detector rows, iCT Philips,was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/10/26
      • Lungs:
        • extensive, bilateral, upper lobes predominant, destructive centrilobular emphysema and subpleural paraseptal emphysema/bulla, in the lungs.
        • Multiple randomly distributed pulmonary nodules of varying sizes
        • due to metastases. reticular opacities at LLL and lingula.
      • Mediastinum and hila: a new necrotic lymphadenopathy in Rt paraesophageal region, subcarinal space.
        • Diffuse wall thickening from middle to lower third esophagus, in regression.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall and visible lower neck: regression mestatatic LAP at Rt supraclavicular fossa..
      • Visible abdominal contents: s/p percutsneous gastrostomy.
        • interval increase in size metastatic lymphadenopathy at para-aortic region near celiac trunk, with invasion to the pancreas.
        • multiple small hepatic cysts and small metastatic tumors are found. several small bilateral renal cysts.
    • Impression:
      • interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
  • 2023-01-02 CXr
    • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2022-11-02 Patho - esophageal biopsy
    • Labeled as “lower esophagus”, biopsy — Ulcer.
    • IHC stains: CK highlights surface squamous mucosa. P40 (-).
    • Section shows surface squamous mucosa, abundant cell debris and acute inflammatory exudates.
  • 2022-11-02 Patho - esophageal biopsy
    • Stomach, PW of upper body, biopsy — Ulcer, H pylori NOT present.
    • Section shows benign gastric mucosal tissue and ulcer debris with chronic inflammation. H. pylori NOT present.
    • NOTE: Since malignancy is clinically suspected, further work up or repeat biopsy might be considered.
  • 2022-11-02 SONO - abdomen
    • Liver cyst, both lobe
  • 2022-11-02 Miniprobe Endoscopic Ultrasound
    • Indication: Esophageal cancer, s/p CCRT, for restaging
      • Esophageal cancer staging
      • Symptoms: Nil
      • Dysphagia
      • Pre-EUS diagnosis: Esophageal cancer
    • Endoscopic findings:
      • With NBI-ME, no lesion nor brownish area was noted above epiglottis or at bilateral pyriform sinuses. With whitelight endoscopy, an easily touch-oozing scar was noted at 29cm below the incisors, causing luminal stenosis. The magnified endoscope could not pass through the stenotic site. With NBI-ME, non-specifc JES-IPCL pattern was noted over the scar and focal JES-IPCL B1 pattern was noted near the scar. We changed the scope to ordinary GIF scope and could pass through the stenotic site with resistance. A PEG tube was noted at AW of lower body. A healing ulcer with surrounding fold convergence was noted at PW of upper body, s/p biopsy(A). A kissing scar was noted at duodenal bulb. Chromoendoscopy with lugol solution showed circumferential LVL with pink-color sign from EC junction to 29cm below the incisors, s/p biopsy(B).
    • EUS findings:
      • With UM-2R, EUS showed 4th layer destruction, at least 3cm in length by miniprobe measurement. A 6.1mm hypoechoic lesion was noted near EC junction.
    • Diagnosis:
      • C/W esophageal cancer, middle to lower esophagus, EUS restaging at least cT3N1, s/p biopsy(B)
      • Gastric ulcer, PW of upper body, H2, Forrest III, suspected malignancy but improved, s/p biopsy(A)
      • PEG in situ
      • Duodenal ulcer scar, bulb
    • Suggestion:
      • Consider to correlate to other image studies and pursue pathology report
  • 2022-10-31 Tc-99m MDP whole body bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, L-S junction, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
  • 2022-10-29 MRI - brain
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • some white matter gliosis in the bilateral frontal lobes
    • IMP: no evidence of brain metastasis.
  • 2022-10-28 CT - chest
    • Indication: esophageal cancer
    • Findings
      • Chest:
        • Diffuse wall thickening from middle to lower third esophagus is found.
        • Severe Emphysematous change over both lungs is found.
        • Nodular lesion at subpleural region of right lower lobe up to 0.7cm and left lower lobe up to 0.5cm is found. These nodules are new.
        • S/p port-A placement with its tip at Superior vena cava.
        • Mild pericardial effusion is found.
        • No evidence of bilateral pleural effusion.
        • Lymphadenopathy at supraclavicular region is found. In regressionn.
      • Visible abdomen:
        • s/p gastrostomy. -Lymphadenopathy at retroperitoneum near celiac trunk is found. In enlargement. -The GB is well distended without soft tissue lesion -The liver, spleen, pancreas, both kidneys and adrenals are intact. -There is no evidence of paraarotic LAPs. -Suggest clinical correlation
      • Imp:
        • Severe COPD.
        • Esophageal cancer with regression.
        • NEw Right lower lobe and left lower lobe nodules. suspected lung meta.
        • Lymphadenopathy at supraclavicular region, in regression.
        • Lymphadenopathy at retroperitoneum, in enlargement.
  • 2022-10-28 Nasopharyngoscopy
    • Bil. few thick mucus and nasal cavity, suspected chronoic rhinosinusitis.
  • 2022-10-27 Body fluid cytology - bronchial washing
    • Atypia
  • 2022-10-27 Whole body PET scan
    • Glucose hypermetabolism involving the lower portion of the esophagus and cardia of the stomach, compatible with primary malignancy involving these regions.
    • Glucose hypermetabolism in multiple lymph nodes in the right lower neck, right paratracheal, precarinal, gastric cardiac and abdominal left paraaortic regions. Metastatic lymph nodes may show this picture.
    • A glucose hypermetabolic lesion in the segment IVb of the liver. Liver metastasis should be watched out.
    • Some glucose hypermetabolic lesions in bilateral lung fields. The nature is to be determined (inflammation? metastases?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake/accumulation in the left neck muscle, bilateral kidneys, ureters and colon. Physiological FDG uptake/accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-10-27 Bronchoscopy
    • nasal mucosa chronic inflammation
    • No evidence of trachea or LLL bronchus invasion of esophageal cancer
    • COPD AE during scopy
    • Diffuse proximal airways mucus impaction
  • 2022-10-26 CXR
    • Increased lung volume and areas of hyperlucency and decreased upper lung vascular markings due to severe emphysematous change of both lungs upper lung predominance
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • 2022-09-16 CXR
    • Atherosclerotic change of aortic arch
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to suspected old inflammatory process.
  • 2022-08-10 KUB
    • S/P gastrostomy.
    • Radiopaque spot(s) at left renal region suspected renal stone(s).
    • Intact bony structure(s).
  • 2022-08-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (134 - 43) / 134 = 67.91%
      • M-mode (Teichholz) = 67.8
    • Dilated LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR
  • 2022-08-01 Tc-99m MDP whole body bone scan with SPECT
    • Several faint hot spots in the right rib cage, and increased activity in some T- and L-spine, and L-S junction, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, left sternoclavicular junction, bilateral shoulders, and S-I joints.
  • 2022-07-30 CT - chest
    • Indication: esophageal tumor, lower esophagus
    • Findings
      • Chest:
        • Dilated upper esophagus with soft tissue occupying middle to lower esophagus about 10.3cm in largest dimension.
        • Lymphadenopathy at right lower neck, paratracheal, paraesophageal, gastric cardiac and retroperitoneal region.
        • There is no evidence of destructive bone lesion.
        • Severe Emphysematous change over both lungs.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Multiple hepatic cysts are found at both lobes of liver is found.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
    • Imp:
      • Esophageal cancer at lower third esophagus and extensive lymphadenopathy. Suggest further treatment.
      • Severe Emphysematous change over both lungs.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-07-29 Patho - esophageal biopsy
    • Esophagus, 30-40 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • Esophagus, 40-42 cm below the insicors, biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
    • Stomach, cardia, biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of gastric mucosal tissue with nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.

[consultation]

  • 2022-10-28 ENT
    • Q
      • This 63-year-old man has squamous cell carcinoma of middle to lower third esophagus, with caria involvement, cT3N3M0, stage IVA. He underwent neoadjuvant CCRT and visited our oncologist OPD for regular follow-up. This time, he was admitted for cancer restaging. Due to nasal mucosa lesion noted during bronchoscope on 2022-10-27. Thus we need your professional evaluation and suggestion. Thank you very much.
    • A
      • Local finding via scope (PACS):
        • Bil. few thick mucus and nasal cavity, suspected chronoc rhinosinusitis
        • No obvious abnormal lesion was noted via this exam
      • Suggestion:
        • OPD f/u for his chronoc rhinosinusitis is enough
  • 2022-08-05 Radiation Oncology
    • A
      • A: Squamous cell carcinoma of the M-L/3 esophagus, with gastric involvement, stage cT3N3M0.
      • P: CCRT is indicated for this patient with the following indicators: esophageal cancer with gastric involvement, stage cT3N3M0.
        • Goal: palliation
        • Treatment target and volume: esophageal tumor, peripheral involved and regional involved nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5040cGy/28 fractions of the esophageal tumor, peripheral involved and regional involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-08-09.
  • 2022-08-02 Hemato-Oncology
    • Q
      • For CCRT surveillance
      • This is a 63 y/o male with history of hyperthyroidism (subclinical?) without medical treatment.
      • He was admitted for tumor work-up and treatment due to unintentional BW loss, esophageal and gastric tumor noted via PES on 20220728.
      • Pathological study showed squamous cell carcinoma. We sincerely need your expertise for CCRT evaluation and management.
    • A
      • This 63-year-old man was consulted and evaluated for esophageal cancer and CCRT
      • A:
        • esophagel cancer, with partial obstruction.
      • Recommendation:
        • CCRT is indicated for this patient
        • suggest port-A implantation and feeding jejumstomy for nutrition

[surgical operation]

  • 2022-08-08 laparoscopic gastrostomy and port-A implantation

[chemoimmunotherapy]

  • 2023-01-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-11 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-09-16 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-19 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-02-10

  • After the last round of chemotherapy (in early Jan 2023), he suffered from severe diarrhea for seven days and poor intake of food.
  • Chest CT images (2023-01-18) and abdomen CT images (2023-02-10) indicated that the disease is progressive.
  • A subsequent line treatment with paclitaxel 50 mg/m2 and carboplatin AUC 2 weekly for 5 weeks could be considered optionally.

2023-01-03

  • As part of the admission diagnosis, COPD with (acute) exacerbation is present, however, the Sp02 remains at no less than 94% according to vital sign records in this hospitalization.
  • Here are a few signs to watch for: diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, use of accessory muscles, brief and fragmented speech, inability to lie supine, profound diaphoresis, agitation, and an asynchrony between respiration and chest and abdominal movements.
  • In the event that exacerbations occur:
    • Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from metered dose inhaler (MDI) every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed.
    • Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses.
    • Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours).
  • A slightly low level of serum Na, K, and Mg was found in the 2023-01-02 lab result. Corresponding supplements were administered.

701463803

230210

[exam findings]

  • 2023-01-20 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, lower C-spine, middle and lower T-spines, some L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower C-spine, middle and lower T-spines and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2023-01-18 ECG
    • Possible Left atrial enlargement
    • Left axis deviation
    • Nonspecific T wave abnormality
  • 2022-12-30 SONO - abdomen
    • Findings:
      • The liver shows normal in size and echogenicity without focal lesion.
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • The gallbladder appears normal in wall thickness and size.
        • There is no evidence of stone, polyp or sludge.
      • The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • The spleen shows normal in size and echogenicity without focal lesion.
      • Abdominal aorta and IVC show unremarkable finding.
      • There is no evidence of para-aortic lymphadenopathy or ascites.
      • Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • Normal sonographic study of the hepatobiliary system.
  • 2022-12-23 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, modified radical mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, modified radical mastectomy — Free
      • Lymph node, level I and level II, left axilla, modified radical mastectomy — Metastatic carcinoma (1/12)
      • AJCC 8 th edition, Pathology stage: pT4bN1a(cM0); Anatomic stage IIIB; Prognostic stage IIIB
    • MACROSCOPIC EXAMINATION
      • Breast Size: 18 x 12 x 5.0 cm
      • Skin Size: 11.5 x 4.5 cm
      • Nipple: Not retracted
      • Tumor Size: 3.5 x 3.0 x 2.5 cm
      • Resection Margin: Free, 0.1 cm from the deep margin
      • Lymph nodes, left axillary: Level 1 and level 2
      • Representative parts are taken for section and labeled: A1=lateral margins, A2-A8= tumor, B1-B4= left axillary LN, level I, C= left axillary LN, level II
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3.5 x 3.0 x 2.5 cm
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
      • Skin involvement with ulcer: Present
      • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin (1 mm from deep margin)
      • Nodal status: Positive (level I 1/11; level II 0/1)
        • number of lymph node examined: 11 (level I), 1 (level II)
        • number with macrometastases (>2mm): 1 (level I)
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
      • Extranodal extension: Not identified
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Present
    • IMMUNOHISTOCHEMICAL STUDY (at Kaohsiung Armed Forces General Hospital)
      • ER (Ab): Positive (90%, 3+)
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative
      • Ki-67: 5%
  • 2022-12-21 CT - chest
    • Indication: Malignant neoplasm of central portion of left female breast
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at left axillary region is found.
        • Soft tissue mass at left breast up to 2.8cm is found.
        • Minimal atelectatic change at right middle lobe is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left breast cancer with left axillary lymphadenopathy
  • 2022-12-21 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-12-21 Spirometry
    • Mild restrictive ventilatory impairment
  • 2022-12-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92.4 - 23.4) / 92.4 = 74.68%
      • M-mode (Teichholz) = 74.7
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR
  • 2022-12-20 External Eye Photography
    • cataract

[chemotherapy]

  • 2023-02-10 - Endoxan (cyclophosphamide) 600mg/m2 836mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • 2023-01-19 - Endoxan (cyclophosphamide) 600mg/m2 823mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • package insert
    • Endoxan: WBC > 2500
    • Lipo-Dox: ANC > 1500

[assessment]

  • 2023-02-09 WBC 1.74 *10^3/uL, Neutrophil 52.4%, Band 0.0% => ANC 912/mm3 grade 3 neutropenia. In the case of grade 3 neutropenia, chemotherapy is not recommended.
  • If the patient’s granulocyte count needs to be increased within a short period of time, 250ug of Granocyte (lenogastin) or 150ug of G-CSF (filgrastim) is recommended for two or three consecutive days. However, please do not administer G-CSF in the period 24 hours before to 24 hours after administration of cytotoxic chemotherapy because of the potential sensitivity of rapidly dividing myeloid cells to cytotoxic chemotherapy.
  • It is suggested to closely monitor any signs of infection.

700702162

230206

[diagnosis] - 20230203 admission note

  • Intrahepatic bile duct carcinoma
  • Malignant neoplasm of larynx, unspecified
  • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09), PD with spleen metastasis, stage IV on 2022/06/23 s/p plliative chemotherapy with FOLFOX from 2022/08/12 ~ 2022/10/21 for 5 cycles with liver metastasis s/p Target therapy with Lenvatinib (self pay) from 2022/11/16
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension

[past history]

  • Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at NTUHon 2017-04 ~ 2017-06
  • HBV under HBs(+) noted 30+ y/o, Hepatitis flare 2012-04 ~ (HBVDNA 1.36*7iu/ml) HBs(+>250iu/ml) HBe(-) antiHBe(+). PegIFN (Roche), 2012-09-12 ~ NHI 2012/09/14 ~ 2013/01 ETV NHI 2013/01/04 ~, self-paid 4/wk 2016/01/05 ~
  • DM with diet control 60 y/o~
  • Hypertension regular Olmetec 20mg 1# po QD tx 55 y/o~
  • Vocal cord SCC 28 y/o Cardinal Tien Hospital post R/T NTUH 2017/04 ~ 06    

[allergy]

  • Naproxen (KNAPO02): skin rash
  • Trimethoprim, Sulfamethoxazole (KBAKT01): slight ???

[exam findings]

  • 2023-02-03 KUB
    • Scoliotic alignment of the lumbar spine is found.
    • Phlebolith at pelvic cavity is also found.
  • 2023-02-03 CXR
    • Nodular lesion at right central lung is found.
  • 2023-01-31 CT - abdomen
    • History and indication: Intrahepatic cholangiocarcinoma
    • Findings
      • Some hypodense lesions (up to 3.3cm) in liver. A small enhancing tumor (1.6cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
      • Multiple nodules in bil. lungs.
      • Wall thickening of A-colon. Minimal ascites.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Duodenal diverticulum.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • A recurrent tumor (1.6cm) at liver dome.
  • 2022-10-24 CT - abdomen
    • Indication:
      • Intrahepatic bile duct carcinoma with splenic mets s/p OP and RFA
      • Malignant neoplasm of larynx, unspecified
    • Abdominal CT with and without enhancement revealed:
      • Abdomen
        • s/p right hepatic op.
        • Several low density lesions scattered at both lobes of liver is found up to 3.53cm at S4. Liver meta is considered. In comparison with CT dated on 2020-08-10, progession of the tumors are found.
        • Lymphadenopathy at hepatic hilum, mesenterric region and gastrohepatic ligment and paraaortic region is found.
        • MInimal ascites is found.
        • The GB is well distended without soft tissue lesion
        • The urinary bladder is well distended without soft tissue lesion.
        • The spleen, pancreas, both kidneys and adrenals are intact.
      • Visible chest
        • Normal heart size.
        • The lung fields are clear.
        • No pleural effusion is found.
    • Imp: Multiple liver meta with lymphadenopathy in the abdominal cavity.
  • 2020-08-10 CT - liver, spleen, biliary duct, pancreas
    • History and indication: cancer F/U
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A small enhancing tumor (1.1cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Duodenal diverticulum.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • A recurrent tumor (1.1cm) at liver dome. S/P right hepatic lobe operation. Grade 4 fatty liver.
  • 2020-06-03 Patho - liver partial resection
    • Diagnosis
      • Liver, S7, resection — Cholangiocarcinoma
    • Gross Description:
      • Procedure: S7 partial hepatectomy, 7 x 6 x 3 cm, 70 gms
      • Tumor Focality: Solitary
      • Tumor Site: Right lobe S7
      • Tumor Size: 2.2 x 2.0 x 1.8 cm , 2.0 cm away from closest margin
      • Non-tumorous part: cirrhotic
      • Gallbladder: size: not received.
      • Sections are taken and labeled as: A1-2: tumor with margins; A3-4: tumor; A5: non-tumor.
    • Microscopic Description:
      • Diagnosis: Intrahepatic cholangiocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Growth Pattern: Mass-forming
      • Tumor Extension: Tumor confined to hepatic parenchyma
      • Parenchymal Margin Uninvolved by invasive carcinoma
      • Bile duct Margin Uninvolved by invasive carcinoma
  • 2020-05-19 Visceral Angiography 2 vessels
    • DSA of celiac trunk, common hepatic artery and SMA with post-angiography CTAP study via right common femoral artery puncture revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Patency of portal vein.
      • A faint enhancing tumor at right hepatic lobe.
      • Post-angiography CTAP images also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
      • No procedure-related complication during the whole procedure.
    • IMP: Right liver tumor, HCC is first considered.
  • 2020-05-15 CT - liver, spleen, biliary duct, pancreas
    • Indication:
      • 2015-08-14 HBV
      • 2020-05-12 US: susp tumor 17mm, > CT HBs(+) noted 30+y/o, HBe(-) antiHBe(+)
      • Vocal cord SCC 28y/o at Cardinal Tien Hospital and post R/T at NTUH 2017/4~6
      • FH: senior brother HBs + Cholangioca died 58y/o.
    • Findings:
      • There is an ill-defined hypodense mass lesion measuring 1.8 x 1.3 cm in S6 of the liver subcapsule area. During dynamic study, this mass shows mild contrast enhancement in arterial phase images and contrast washout in portal venous phase and delayed phase images.
        • HCC is highly suspected. The differential diagnosis include cholangiocarcinoma.
        • Please correlate with AFP and contrast enhanced dynamic MRI.
      • A hepatic cyst measuring 0.4 cm in S3 is suspected. Please correlate with sonography.
      • There is a diverticulum measuring 2.9 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
    • Imaging Report Form for Cholangiocarcinoma
      • Impression (Imaging stage): T:T1a (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IA(Stage_value)
  • 2020-05-04 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Parenchymal liver disease, mild
      • Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe)
      • Suspected tiny GB polyps
    • Suggestion
      • Correlate with CT or MR
      • Check AFP
  • 2019-11-05 SONO - abdomen
    • Findings
      • Smooth liver surface. Small anechoic lesion about 0.5cm was noted at left lobe.
      • No gall stone. Small polyp about 0.2cm was noted on the gallbladder wall. No CBD dilatation.
    • Diagnosis
      • Liver cyst, left lobe
      • Gallbladder polyp
  • 2019-04-03 SONO - abdomen
    • Findings
      • Increased brightness, far attenuation and increased hepatorenal contrast
      • A few cysts were detected and the largest one 0.7 cm in size, was at S5
      • 2/3 pancreas was mask by bowel gas
      • Increased brightness of pancreas
    • Diagnosis
      • Fatty liver, mild
      • Fatty infiltration of pancreas
      • Liver cysts
  • 2018-09-19 SONO - abdomen
    • Findings
      • Increased brightness of echotexture. One 0.70cm anechoic cystic lesion with posterior enhancement at S5.
      • One 0.35cm hyperechoic lesion within GB lumen. No dilatation of CBD.
    • Diagnosis
      • Fatty liver, mild
      • Hepatic cyst, right
      • GB polyp
  • 2018-03-23 SONO - abdomen
    • Findings
      • Size normal; Surface smooth; Edge sharp; Vessel well-defined; Echotexture: increased hepatorenal echocontrast; One hypoechoic lesion about 0.8cm was found at the right anterior segment
      • One hyperechoic lesion about 0.4 cm in the GB; Normal GB wall thickness; No biliary tract dilatation
    • Diagnosis
      • Fatty liver,mild
      • Suspected liver cyst,right
      • Suspecetd GB polyp
      • Pancreas not shown
  • 2017-09-21 SONO - abdomen
    • Findings
      • bright echo appperance with increased hepatorenal contrast, mild
      • obliteration of portal tract; a 0.77-cm anechoic lesion at seg5
      • a 0.48-cm polyp in GB ; no biliary tract dilatation.
    • Diagnosis
      • mild fatty liver
      • liver cyst
      • GB polyp
  • 2017-03-22 SONO - abdomen
    • Indication: Hepatitis
    • Findings
      • Mildly bright liver echo comparing with renal cortex.
      • A 8-mm cyst in liver, right lobe.
      • A 6-mm polyp in GB. No biliary dilatation.
      • pancreas ~60% visible
    • Diagnosis
      • Mild fatty liver + Right Liver cyst
      • GB polyp

[consultation]

  • 2023-01-17 Dermatology
    • Q
      • This 64-year-old male patient has past history of 1) Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at National Taiwan University Hospital on 2017/04 ~ 2017/06; 2) HBV under ETV (4/wk) tx (self-paid), 3) Hypertension, he was regularly followed up at OPD. According for his statement, abdominal sonography on 2020/05/04 showed 1) Fatty liver, mild; 2) Parenchymal liver disease, mild; 3) Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe); 4) Suspected tiny GB polyps. Further Abdominal CT was perfromed on 2020/05/17 and revealed 1) HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Alpha-feto-protein (AFP) was 3.0ng/dl on 2020/05/04. Angio CT on 2020/05/15 also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
      • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09). Liver tumor biopsy on 2020/06/03 and pathology showed cholangiocarcinoma. PD in new lesion over spleen based on the findings of CT on 2022/06/24.
      • He was transfer to our hospital for further treatment. The patient has been informed again palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 and 5HT3 are not covered by NHI) on 2022/08/12. Palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 self pay, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/8/12(C1D1), 2022/08/26(C1D15), 2022/09/13(C2D1), 2022/10/05(C2D15), 2022/10/21(C3D1). Abdominal CT on 2022/10/24 showed multiple liver metastases with lymphadenopathy in the abdominal cavity. Target therapy with Lenvatinib (self pay) from 2022/11/16. Now, he was admitted to ward for target therapy with Lenvatinib (self pay).        
      • For Lenvatinib related side effect of hand, we need your further evaluation and management.
    • A
      • The patient had sufferred from mutiple erythematous plaques with thick scales and erosion.
      • Under the impression of hand-foot syndrome after chemotherapy and target therapy.
      • The following sugeetion:
        • Tetracycline onit 2 tube topical bid use on the wound and erosive lesions first.
        • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use after body clean for skin mositurization and keratolytic effect.
        • If new erythema lesions development, consider Topysm cream (fluocinonide) 1 tube topical bid use for anti-inflammation.
  • 2020-05-18 Radiation Oncology
    • Q
      • for arrange angiography with CTAP (computed tomography arterial portography)
      • This 61 year-old male of DM, HBV.
      • Abdominal CT showed HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Please correlate with AFP and contrast enhanced dynamic MRI. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition, CT staging of HCC: T1N0Mx, Staging: I.
    • A
      • According to the clinical condition and imaging findings, angiography with CTAP study is indicated.

[chemotherapy]

  • 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-10-05 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-09-13 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[medication]

  • Lenvima (lenvatinib) KLENV02
    • 2022-11-16 ~ undergoing 10mg QD
  • Baraclude (entecavir) KBARA01
    • 2022-11-02 ~ undergoing 0.5mg QDAC
    • 2020-08-21 ~ + 84 days 0.5mg QDAC

==========

2023-02-06

  • 2023-02-06 lab data showed low Na, low K, low Mg, low Ca in the blood, Nako No.5 electrolyte solution has been provided appropriately.
  • Due to the patient’s blood pressure level staying at 90/50 for the past two days, it is not necessary to lower his blood pressure further. Please temporarily hold the self-carried Olmetec (olmesartan).
  • Please follow up with the patient to determine whether the hand-foot syndrome is improving, if not, topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) can be applied again.

2023-01-18

  • Because lenvatinib has a moderate to high emetic potential, the antiemetic agent metoclopramide has also been prescribed appropriately in combination with lenvatinib.
  • Lenvatinib’s dermatologic adverse reactions include: alopecia (12%), palmar-plantar erythrodysesthesia (27% to 32%), skin rash (14% to 21%). The developed hand-foot syndrome has been referred to a dermatologist and topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) have been prescribed to mitigate the symptoms.
  • As the patient has a history of hypertension, and lenvatinib is also associated with hypertension (45% to 73%; severe hypertension: 3%), it is recommended that blood pressure be closely monitored.

700151650

230203

{not completed}

[exam findings]

  • 2023-02-02 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the middle and lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral wrists, hip and right knee, compatible with benign joint lesion.
    • No prominent bone abnormality was noted elsewhere.
  • 2023-02-02 SONO - chest
    • Echo diagnosis:
      • pleural effusion
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
      • Check bleeding, if bleed from pig tail tube, please call Dr.
      • CxR follow up pig tail tube position.
  • 2023-02-01 Bronchoscopy
    • no endobronchial mass,
    • s/p bronchial washing via RML, sent for TB culture, TB PCR and cytology
  • 2023-01-31 SONO - thyroid gland
    • Normal size of the thyroid gland.
    • Some hypoechoic nodules (up to 0.67cm) in left thyroid gland.
    • Some LNs at bil. neck.
  • 2023-01-19 Cell block
    • PATHOLOGIC DIAGNOSIS
      • Positive for malignancy
      • Immunocytochemistry show TTF-1(+), CK7(+), Napsin-A(+), CK20(-) and CDX-2(-), compatible with metastatic pulmonary adenocarcinoma
      • The smears and cell block show lymphocytes, mesothelial cells and many hyperchromatic atypical epithelial clusters with focal tubular arrangement, compatible with metastatic adenocarcinoma.
  • 2023-01-19 SONO - chest
    • Echo diagnosis:
      • Pleural effusion
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-01-18 CT - chest
    • Findings
      • lungs:
        • a spiculated tumor at mediobasal segment of RLL (31mm in axial dimension) invading adjacent pericardium.
        • partial atelectasis of RML.
        • innumberable randomly distributed pulmonary small nodules of varying sizes due to lung to lung metastases.
        • moderate Rt pleural effusion.
      • Mediastinum and hila:
        • extensive lymphadenopathy in the visceral space, with central necrosis in subcarinal LAP.
      • Aorta:
        • normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart:
        • normal in size of cardiac chambers.
        • mild calcified mitral annulus
      • Chest wall and visible lower neck:
        • suspect metastatic LAP aty Lt supraclavicular fossa.
      • Visible abdominal contents:
        • normal appearance of gall bladder.
        • a small Rt hepatic measurig 10mm.
    • Impression: RLL cancer T4N3M1a(E1)
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1a(M_value) STAGE:____(Stage_value)
  • 2023-01-17 CXR
    • diffuse miliary lesions in both lungs with xonsolidation and volume reduce over Rt lower lung zone and Rt pleural effusion, miliary tuberculosis or metastasis
    • Mild dextroscoliosis of the T-spine
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2023-01-12 Merchant view (patella 45 0) Bil :
    • Lateral subluxation of the patella, Rt
    • Patellofemoral osteoarthritis
    • Sperner classification: 3, 3
  • 2023-01-12 Knee BIL standing AP and Lat
    • Moderate to severe osteoarthritis of both knees, Rt > Lt
    • Ahlback calcification: grade 4, 3
  • 2022-08-15 Peripheral Vascular Test - Vein, lower limbs
    • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level (Tortuous change at lower leg level). Slow venous return flow at left popliteal vein; atleast two perforator veins connecting the left PTV and LSV at left proximal to middle lower leg level were detected.
    • Slow venous return flow at left popliteal vein; atleast three perforator veins connecting the right PTV and LSV at right proximal to distal lower leg level were detected.
    • No evidence of venous thrombosis at bilateral lower limbs venous systems.
    • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2022-08-02 ENT Hearing Test
    • Reliabilty Fair to Poor, 50dB
    • PTA
      • R’t : 73 dB HL, moderately severe to profound mixed type HL
      • L’t : 68 dB HL, moderately severe to profound SNHL
    • Tymp
      • R’t : Type A
      • L’t : Type As.
  • 2022-08-02 Nasopharyngoscopy
    • Findings
      • bil clear nasal cavity; smooth NPx, oropharynx, hypopharynx, no vocal lesion
      • a few whitish discharge coating on pharyngeal wall
    • Conclusion
      • chronic pharyngitis and rhinitis

701456943

230202

[diagnosis] - 2023-01-12 discharge note

  • Adenocarcinoma of rectosigmoid junction status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB
  • Constiplation

[Past History]

  • DM under metformin
  • Adenocarcinoma of rectosigmoid junction status, cT3N2bM0, status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB, LVI(+), PNI(-), CRM(-), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+) , stageIIIC    

[Family History]

  • His mother had colon cancer and DM
  • His younger brother had colon cancer; one of his elder sister had lung adenocarcinoma; one of his elder sister had gastric cancer
  • He denied other systemic diseases

[lab data]

  • 2022-10-20 HBsAg (NM) Negative
  • 2022-10-20 HBsAg Value (NM) 0.424
  • 2022-10-20 Anti-HBs (NM) Positive
  • 2022-10-20 Anti-HBs value (NM) 197
  • 2022-10-20 Anti-HCV (NM) Negative
  • 2022-10-20 Anti-HCV Value (NM) 0.0365

[exam findings]

  • 2022-12-02 Anoscopy
    • Mixed hemorrhoids with congestion
  • 2022-11-04 All RAS + BRAF mutation
    • ALL-RAS:
      • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF:
      • There was no variant detect in the BRAF gene.
  • 2022-10-28 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, RS colon, Laparoscopic low anterior resection — Moderately differentiated adenocarcinoma
      • Distal cut-end: Free
      • Proximal cut-end: Free
      • Lymph node, regiona, dissection — Metatstaic adenocarcinoma (6/17)
      • AJCC 8th edition pathology stage: pT3N2a(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: Laparoscopic low anterior resection
      • Tumor Site: RS colon
      • Tumor Size: 5 x 4 cm.
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as:A:distal cut end, B1-3:LNs, B4-10:tumor, C:proximal cut end
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
        • Distance of tumor from margin: 4 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding:
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
        • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose:Not identified
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes:
        • Number of Lymph Nodes Involved/Examined: 6/17
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT)
            • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN)
            • pN2a: Four to six regional lymph nodes are positive
          • Distant Metastasis (pM):
            • N/A
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
      • Comment(s): None
  • 2022-10-28 Sigmoidoscopy
    • Diagnosis
      • A fungating tumor lesion (3-4cm in size) is located at rectosigmoid junction (15cm AAV)
      • A middle rectal diverticulum
    • Suggestion
      • suggest operation
  • 2022-10-21 CT - abdomen
    • History: passage of bloody stool, change in bowel habit, decrased stool caliber for weeks. tumor of RS-colon at YongHe local clinics.
    • Findings:
      • There is segmental wall thickening of the recto-sigmoid colon, measuring 1.3 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There is a small poor enhancing lesion measuring 5 mm in S2 of the liver that may be cyst? Please correlate with sonography.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)

[surgical operation]

  • 2022-10-03
    • Surgery
      • Laparoscopic low anterior resection     
    • Finding
      • A fungating 4-5cm tumor is located at RS-colon. Some adhesions over small bowel and S-colon mesentery was found, and adhesiolysis was done.    
      • Radical proctectomy (low anterior resection) with total mesorectal excision was carried out smoothly. Blood loss was about 30ml.    
      • Anastomosis was achieved using endo GIA 601+ 451/ green, + CDH-33 + TISSEEL 4ml. Air test is ok.     
      • A drain in pelvis, 4DF 3g was applied for prevent adhesions.  

[radiotherapy]

  • 2022-12-05 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor bed: 54 Gy/ 30 fx.

[chemotherapy]

  • 2023-02-01 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2023-01-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2022-12-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2022-12-05 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg

[assessment]

  • The lab results (2023-02-01) were grossly normal.
  • Metformin (prescribed by a local clinic) is not included on the active medication list despite the fact that the patient has a history of diabetes.
  • If there are no contraindications, the addition of metformin is recommended to maintain stable blood sugar control.

700508887

230201

  • diagnosis
    • 2023-01-11 admission note - Acute lymphoblastic leukemia not having achieved remission
    • 2022-12-21 OPD assessment - MDS is considered with Karyotype: 45~46,XX,+1,der(1;16)(q10;p10)[cp7]/46,XX[7]
    • 2022-12-09 OPD assessment - MDS is considered
  • past history - 20230111 admission note
    • Myelodysplastic syndrome diagnosed on 2022-12-05 by BM biopsy
    • Hypertension for years, with medication (Aprovel) control and regular follow-up at Cardinal Tien Hospital
    • Hyperlipidemia for years, with medication (Livalo) control and regular follow-up at Cardinal Tien Hospital
    • Thrombocytopenia since 2015, and regular follow-up at Cardinal Tien Hospital
  • allergy
    • NKDA
  • family history
    • Mother: Hypertension.
    • Deny any cancer history
  • exam findings
    • 2023-01-11 CXR
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.
    • 2022-12-05 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Normal cellularity with presence of blasts; Suspicious for myelodysplastic syndrome
        • NOTE: Correlation with peripheral blood test, bone marrow smear, flow cytometry, molecular genetic study and clinical findings is recommended.
      • Microscopically, it shows normal cellularity for age (40%), 3:1 of M:E ratio and presence of trilineage marrowe component. Occasional megakaryocytes are seen. Blasts are highlighted by CD34 and CD117 (<20%).
      • Immunohistochemical stain reveals MPO (focal +), CD71(focal+), CD20(focal+), CD138(focal+), CD10(-) and TdT(-).
    • 2022-12-02 CXR
      • cardiomegaly; mediastinal widening

==========

2023-02-01

[potential drug interactions]

  • Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.

  • According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.

  • There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.

2023-01-11

There is no specific pharmacist shift handover to follow in this patient.

[drug identification]

  • A request has been made for us to identify drugs for 3 items.
  • In total, 3 items have been identified as follows, with 0 item remaining unidentified.
    • Doxynin (doxycycline 100mg)
    • Welizen (famotidine 20mg)
    • Flamquit (diclofenac potassium 50mg)
  • These drugs will be sent back to ward by the in-hospital porter.

701352128

230201

[diagnosis] - 2023-02-01 discharge note

  • Gastric cancer with liver metastasis status post total gastrectomy with D2 and dissection, S2-3 left lateral segmentectomy, S6-7 partial hepatectomy and S4-8 alcohol injection on 2021-12-16, stage IV.
  • Chronic viral hepatitis B without delta-agent, 2022/12/23 Anti-HBc: postive

[lab data]

  • 2022-12-26 HBV-DNA-PCR Target Not Detected IU/mL
  • 2022-12-23 Anti-HBc Reactive
  • 2022-12-23 Anti-HBc-Value 4.82 S/CO
  • 2021-12-13 HBsAg Nonreactive
  • 2021-12-13 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-01-31 CT - abdomen
    • Clinical history: 70 y/o male patient with Gastric cancer (pathology showed poorly adenocarcinoma) with outlet obstruction.
    • Impression:
      • S/P total gastrectomy.
      • Ascites with pleural effusion and basal lung atelectasis, progression.
      • Minimal pericardial effusion.
  • 2022-10-12 CT - abdomen
    • History and Indication:
      • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
      • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
      • 20211215 CT: gastric cancer & liver metas? cT4aN3aM1, csTAGE:IVB
      • 20211217 S/P total gastrectomy: pT4aN3bM1, pstage:IV
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings - Comparison: prior CT dated 2022/03/16.
      • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
        • S/P total gastrectomy.
        • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
      • Prior CT identified three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver are not noted again that are c/w metastases S/P C/T with complete response.
      • Prior CT identified A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is not noted again.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
  • 2022-06-23 CT - abdomen
    • History and indication: Gastric cancer with liver metastasis
    • IMP:
      • Gastric cancer s/p operation. Minimal ascites in pelvic cavity.
      • Much regression of liver lesions.
  • 2022-03-16 CT - abdomen
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P total gastrectomy.
      • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
      • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
      • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
        • Primary lung cancer is suspected.
        • The differential diagnosis include Metastasis.
        • Follow up is indicated.
    • Impression:
      • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
      • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
        • Primary lung cancer is suspected.
        • The differential diagnosis include Metastasis.
        • Follow up is indicated.
  • 2021-12-20 Upper GI series
    • S/P gastrectomy. No evidence of contrast medium leakage.
    • Normal contour and mucosal pattern of the esophagus.
    • Right CVP inserted to SVC in position.
    • Compression fracture of spine.
  • 2021-12-17 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S2-3, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
      • Liver, S6-7, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
    • MACROSCOPIC EXAMINATION
      • Procedures: Partial hepatectomy of S2-3 and S6-7
      • Specimen Size: 12 x 5.0 x 4.0 cm and 130 gm (S2-3); 3.0 x 2.0 x 1.2 cm (S6-7)
      • Tumor Focality: Multiple; number: 3 (S2-3) and 1 (S6-7)
      • Tumor Site: S2-3 and S6-7
      • Tumor Size: 1.4 x 1.2 cm, 1.2 x 0.9 cm, 0.2 x 0.2 cm (S2-3), and 0.8 x 0.6 cm (S6-7), respectively
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= S2-3 tumors, B1-B2= S6-7 tumor
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic gastric adenocarcinoma
      • Histologic grade: Poorly differentiated
      • Tumor growth pattern: Infiltrating
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Present
      • Parenchymal margin: Uninvolved by carcinoma
      • Vascular invasion: Present
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal
  • 2021-12-17 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Mixed tubular adenocarcinoma and poorly cohesive carcinoma
      • Margins, bilateral cutting ends, total gastrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (46/60)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN3bM1, stage IV
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, omentum
      • Specimen size: (a) Stomach: 31.5 cm along the greater curvature and 16.0 cm along the lesser curvature (b) Omentum: 35 x 22 x 5 cm
      • Number of lesions: Solitary
      • Tumor site: Antrum to cardia, lesser curvature, 3.5 cm from distal margin
      • Tumor size: 12.5 x 11.0 cm
      • Tumor configuration: Ulcerative tumor
      • Representative sections as follows: A1= distal cut end, A2-A5= tumor with lesser curvature LNs, A6-A7= tumor at antrum, A8= tumor at body, A9-A10= tumor at fundus and cardia, B1-B2= omentum, C= esophageal margin, D1-D4= LN 1, E1-E2= LN 2, F1-F5= LN 4, G1-G2= LN 5, H1-H2= LN 6, I1-I4= LN 7,8,9,11,12a,16, J1-J2= LN 10, K1-K2= LN 14. F2021-00500FS= esophageal cut end received for frozen section
    • MICROSCOPIC EXAMINATION
      • Histologic type: Mixed tubular adenocarcinoma and poorly cohesive carcinoma (Lauren classification: mixed type)
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: <1 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic adenocarcinoma (46/60) 8/8 (lesser curvature LNs), 0/1 (omentum LN), 12/14 (LN 1), 0 (LN 2), 14/14 (LN 4), 1/2 (LN 5), 4/5 (LN 6), 4/8 (LN 7, 8, 9, 11, 12a, 16), 0/1 (LN 10), 3/7 (LN 14) (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Omentum: Free of tumor invasion
      • Additional pathologic findings: Liver metastasis (S2021-18735)
      • Pathologic Staging: pT4aN3bM1, stage IV
      • IHC: HER2(Negative, score= 0)
      • Esophageal margin (including frozen section specimen): Free of carcinoma
  • 2021-12-15 CT - abdomen
    • History and Indication:
      • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
      • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
    • Findings:
      • There is an ill-defined poor enhancing mass measuring 1.5 cm in S2 dome of the liver at portal venous phase images and suggestive enhancement in delayed phase images.
        • In addition, there are two lesions measuring 0.5 cm in S4 and 0.7 cm in S5, showing similar feature.
        • Metastases are highly suspected.
        • The differential diagnosis include hemangioma.
        • Please correlate with MRI.
      • There is wall thickening at the gastric antrum measuring 1.3 cm in wall thickness. Please correlate with gastroscopy.
        • In addition, there are seven enlarged nodes in the gastrohepatic ligament, celiac trunk, and hepatoduodenal ligament that may be metastatic nodes.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N3a (N_value) M:M1 (M_value) STAGE:IVB(Stage_value)
  • 2021-12-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84.4 - 24.6) / 84.4 = 70.85%
      • M-mode (Teichholz) = 70.9
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2021-12-14 Patho - stomach biopsy
    • Stomach, prepyloric antrum, biopsy— poorly differentiated adenocarcinoma with focal signet-ring cell differentiation
    • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of neoplastic cells arranged in solid to glandular architecture, and focal signet-ring cell diffferentiation.
  • 2021-12-14 SONO - abdomen
    • Hepatic tummor, nature to be determinated
  • 2021-12-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal study due to much semi-fluid residue retention
      • Ulcerative tumor, preplyoric antrum and probable low body, s/p biopsy x6
    • Suggestion
      • Pursue biopsy result
  • 2021-12-13 Spirometry
    • normal spirometry

[consultation]

  • 2021-12-24 Radiation Oncology
    • Q
      • This 69 y/o male with history of gastric with liver meta then s/p total gastrectomy with LN D2+ dissection and S23 resection + S6-7 partial hepatectomy + S4-8 alcohol injection on 2021/12/16. Pathology showed Mixed tubular adenocarcinoma and poorly cohesive carcinoma. pT4aN3bM1, stage IV. after well improved of general condition and well oral intake, further management of CCRT will plaining. We need your help for RT evaluation. Thanks you!!
    • A
      • A: Mixed tubular adenocarcinoma and poorly cohesive carcinoma of the stomach, AJCC Pathologic staging — pT4aN3bM1, stage IV, with liver metastases, s/p total gastrectomy with LN D2+ dissection, S23 resection, S6-7 partial hepatectomy, S4-8 alcohol injection.
      • P: Radiotherapy is indicated for this patient with the following indicators: stage pT4aN3bM1
        • Goal: palliation
        • Treatment target and volume: gastric tumor bed, peripheral involved including regional lymphatic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gastric tumor bed, peripheral involved including regional lymphatic area
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 8:30, 2022-01-10.

[surgical operation]

  • 2021-12-16
    • Surgery
      • total gastrectomy with LN D2+ dissection
      • S23 resection
      • S6-7 partial hepatectomy
      • S4-8 alcohol injection
    • Finding
      • gastric ca lesser curvature cardia to lowewr antrum with multiple LN enlarge
      • serosa+
      • seeding-
      • multiple liver tumor
      • S2-3 at least 3 nodle 0.2, 0.8 1.2cmS6-7 0.8cm
      • S6-7 0.8 cm
      • S4-8 0,8 x 0.6cm in deep central parancyhma

[radiotherapy]

  • 2022-01-19 ~ 2022-03-02 - 4500cGy/25 fractions (15 MV photon) of the gastric tumor bed, peripheral involved including regional lymphatic area.

[chemotherapy]

  • 2023-01-30 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4775mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-09 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-25 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-10-24 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-27 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-24 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-10 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-27 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-08 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-06-22 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-06-06 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-05-23 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-05-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-04-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-29 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-15 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-01 - fluorouracil 225mg/m2 380mg 24hr D1-2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-21 - fluorouracil 225mg/m2 380mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-14 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-07 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-01-24 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-01-19 - fluorouracil 225mg/m2 390mg 24hr D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

701460262

230201

[diagnosis] - 2023-02-01 discharge note

  • Malignant neoplasm of cervix uteri, unspecified
  • Squamous cell carcinoma, keratinizing, moderately differentiated of the uterine cervix, stage pT1a2 (III), with negative margin (HPV related), s/p laparoscopic assisted vaginal hysterectomy, with local recurrence.
  • Type II diabetes mellitus

[lab data]

  • 2022-11-29 HBsAg (NM) Negative
  • 2022-11-29 HBsAg Value (NM) 0.775
  • 2022-11-29 Anti-HBc Nonreactive
  • 2022-11-29 Anti-HBc-Value 0.19 S/CO
  • 2022-11-29 Anti-HCV (NM) Negative
  • 2022-11-29 Anti-HCV Value (NM) 0.0347

[exam findings]

  • 2022-11-21 MRI - pelvis
    • Clinical history: 42 y/o female patient with cervical CIN 3 and ov tumor said s/p hysterectomy in Keelung CGMH in 2020 , patho revealed cervical cancer (SCC, stage Ia2, patho Number S2020G-15625A), 2021 stump revealed VaIN 3 (S2021G-12951) -> local LASER was done. 2022/11/10 vaginal bleeding, suggest IVRT (intravaginal radiotherapy) if residual cancer tissues noted. next – ask the patient to bring the reports from previous hospital, + MRI + SCC + CEA check.
    • Impression:
      • S/P hysterectomy.
      • Recurrent tumors in the vaginal stump with colon and urinary bladder adhesion/involvement.
      • Cystic lesions, 2.35cm in left pelvic cavity.
  • 2022-11-10 Gynecologic ultrasonography
    • s/p ATH
    • Suspcted Rt Ovarian cyst
  • 2021-11-04 Pathology - vagina biopsy (Keelung CGMH)
    • S2021G-12951A: vagina biopsy — vaginal intraepithelial neoplasia III (VaIn III) — P16(+), suggestive high risk HPV infection.
  • 2020-10-29 Pathology (Keelung CGMH)
    • S2020G-15625A: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a2, wth negative margin (HPV related)
  • 2020-10-26 Pathology (Keelung CGMH)
    • S2020G-15625: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a1, wth negative margin (HPV related)

[surgical operation]

  • 2020 Laparoscopic Assisted Vaginal Hysterectomy, LAVH (Keelung CGMH)

[radiotherapy]

  • 2022-12-09 ~ - at 4500cGy/25 fractions (15 MV photon) of the pelvic area.

[chemotherapy]

  • 2023-01-30 - cisplatin 70mg/m2 115mg 4hr D1 + fluorouracil 1000mg/m2 1660mg 24hr D1 (CCRT)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1
  • 2022-12-15 - cisplatin 70mg/m2 115mg 4hr D1-4 + fluorouracil 1000mg/m2 1660mg 24hr D1-4 (CCRT)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1

700978478

230131

[diagnosis] - 2022-10-01 discharge

  • Squamous cell carcinoma of upper third esophagus cT2N2M0,stage IIA
  • Essential (primary) hypertension
  • Type 2 diabetes mellitus without complications
  • Unspecified viral hepatitis B without hepatic coma
  • Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
  • Hypomagnesemia
  • Constipation, unspecified

[exam findings]

  • 2022-12-23, -12-20, -12-19, -12-16, -12-15, -12-14 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Right internal jugular central venous catheter with tip in the superior cavo-atrial junction
    • s/p right chest tube in place, its tip directed superomedially, projecting over hilar shadow
    • Rt shift of trachea s/p esophagectomy and gastric tube reconstruction s/p gastric tube placement
    • Platelike lung atelectasis over Lt lower lung zone
  • 2022-12-13 Patho - esophagus subtotal/total resection
    • Diagnosis
      • Esophagus, upper third, VATS McKeown esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
      • Stomach, cardia, partial gastrectomy —- Negative for malignancy
      • Thoracic duct, right, excision —- Negative for malignancy
      • Resection margin: Negative for malignancy; cutend of proximal esophagus: Negative for malignancy
      • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
      • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/11)
      • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/15)
      • Lymph node, left, group 4, dissection —- Negative for malignancy (0/3)
      • Lymph node, right, group 7, dissection —- Negative for malignancy (0/3)
      • Lymph node, right, lower paraesophageal, dissection —- Negative for malignancy (0/0)
      • Left recurrent laryngeal nerve and lymph node, dissection —- Negative for malignancy (0/3)
      • Lymph node, left group 9, dissection —- Negative for malignancy (0/0)
      • AJCC 8 th edition pT N M Pathology stage: ypStage I, ypT2N0(if cM0)
    • Gross Description:
      • Procedure: VATS McKeown esophagectomy; Size: Esophagus: 10.0 cm in length with a portion of gastric tissue measuring 2.6 cm in length.
      • Tumor Site: upper esophagus
      • Relationship of Tumor to Esophagogastric Junction: Tumor is entirely located within the tubular esophagus and does not involve the esophagogastric junction
      • Tumor Size: 2.2 x1 .5 cm
      • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: stomach; A4: esophagus;A5: EG junction; A6-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal;A12: lymph node, lower paraesophageal; A13-14: lymph node, perigastric; B1-2: lymph node, right group 2+4; C: lymph node, left group 4; D1-2: lymph node, right group 7; E: right thoracic duct; F: lymph node, right lower paraesophageal; G: left recurrent laryngeal nerve and artery; H: proximal cutend of esophagus; I: lymph node, left group 9.
    • Microscopic Description:
      • Histologic Type: Squamous cell carcinoma, s/p CCRT
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades the muscularis propria
      • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
        • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm
        • Specify closest margin: serosal
        • Proximal resection margin: 1.1 cm
        • Distal resection margin: 9.1 cm
      • Treatment Effect: Present, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response, score 2)
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Regional Lymph Nodes: please see diagnosis
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors: y (posttreatment)
        • Primary Tumor (pT): pT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings: Acute inflammation is seen on serosa.
  • 2022-11-26 MRI - brain
    • IMP: no evidenceof brain tumors.
  • 2022-11-25 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the lower C-spine, lower T-spine, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2022/09/16, no prominent change is noted, suggesting no definite evidence of bone metastasis.
      • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-11-24 Bronchoscopy
    • Normal airways, no evidence of esophageal cancer invasion
    • COPD with some sputum in dependent airways
    • Chronic rhinitis
  • 2022-11-23 Patho - esophageal biopsy
    • PATHOLOGIC DIAGNOSIS
      • Esophagus, upper, 23 cm, biopsy — Squamous cell carcinoma, moderately differentiated
      • Esophagus, upper, 26 cm, biopsy — Chronic esophagitis
      • Esophagus, lower, 35 cm, biopsy — Chronic esophagitis
    • MICROSCOPIC EXAMINATION
      • The sections of specimen (1) show a picture of chronic esophagitis, composed of squamous epithelium with congestion, basal cell hyperplasia, elongation of papillae, moderate inflammatory cells infiltration, and reactive atypia of epithelial cells.
      • The sections of specimen (2) show a picture of squamous cell carcinoma, moderately differentiated, composed of nests of polygonal to oval-shaped neoplastic cells with stroma invasion. Keratin formation is present.
      • The sections of specimen (3) show a picture of chronic esophagitis, composed of squamous epithelium with congestion, parakeratosis, basal cell hyperplasia, elongation of papillae, and mild inflammatory cells infiltration.
  • 2022-11-23 Miniprobe Endoscopic Ultrasound
    • Diagnosis
      • Esophageal cancer, 23cm, EUS staging at least cT2N2, s/p biopsy(C)
      • Lugol voiding area, r/o dysphagia, 35cm, s/p biopsy(A)
      • Lugol voiding area, r/o dysphagia, 26cm, s/p biopsy(B)
      • Gastric subepithelial lesion, fundus, r/o lipoma
    • Suggestion
      • Consider to correlate to other image studies and pursue pathology report
  • 2022-11-23 Cardiopulmonary Exercise Test
    • conclusion
      • maximal exercise
      • low exercise capacity (VO2 59%, WR 75%)
      • low stroke volume response during exercise
      • normal ventilatory function (FEV1/FVC, FVC 87%, FEV1 81%)
      • No SpO2 desaturation during exercise
      • normal respiratory muscle strength (MIP 101%, MEP 79%)
      • Health-related quality of life, CAT= 12, poor, cough, sputum, chest tightness predominant
    • suggestions:
      • treat underlying condition, treat cough, sputum, chest tightnes
      • survey and treat cardiac function
      • Adequate fluid intake to keep adequate stroke volume
      • suggest exercise training after operation
      • low risk for operation
  • 2022-11-22 PET scan
    • In comparison with the previous study on 2022/09/14, the glucose hypermetabolism in the upper portion of the esophagus and some bilateral paratracheal lymph nodes is less evident.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, in bilateral shoulders and in the soft tissues around bilateral hips. Inflammation may show this picture.
    • Increased FDG accumulation in the colon and both kidneys, probably physiological accumulation of FDG.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-09-20 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 36 dB HL; LE 39 dB HL
    • R’t normal to severe SNHL.
    • L’t normal to severe SNHL but have ABG at 1k Hz.
    • 4k Hz notch was noted in both ears.
  • 2022-09-17 MRI - brain
    • No evidence of brain metastases.
  • 2022-09-16 Tc-99m MDP
    • No definite evidence of bone metastasis.
    • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-09-15 Cardiopulmonary Exercise Testing
    • Conclusion
      • maximal exercise
      • low exercise capacity (VO2 73%, WR 67%)
        • normal stroke volume response during exercise
        • normal ventilatory function (FVC 83%, FEV1 82%)
        • Health-related quality of life, CAT = 13, poor
    • Suggestions
      • treat underlying condition
      • suggest exercise training
      • low risk for operation
  • 2022-09-14 Whole body PET scan
    • A glucose hypermetabolism lesion in the esophagus, U/3, compatible with the primary esophageal cancer.
    • Glucose hypermetabolic lesions in bilateral mediastinal space, suspected cancer with regional lymph nodes metastases.
    • Glucose hypermetabolism in bilateral pulmonary hilar regions and in a right level II-III cervical lymph node, probably reactive nodes.
    • Glucose hypermetabolism in the right palatine tonsil, probably chronic inflammation process.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Upper esophageal cancer with two regional lymph nodes metastases, cTxN1M0, by this F-18 FDG PET scan.
  • 2022-09-14 Bronchoscopy
    • no endobronchial lesion
  • 2022-09-13 ECG
    • Sinus rhythm with 1st degree A-V block
    • Incomplete right bundle branch block
  • 2022-09-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 26) / 80 = 67.50%
      • M-mode (Teichholz) = 66
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
  • 2022-08-24 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-08-23 Patho - esophageal biopsy
    • Esophagus, 22-30 cm below incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei with subtle desmoplastic stromal reaction. Keratin formation is evident.
  • 2022-08-22 SONO - abdomen
    • mild tomoderate fatty liver (suboptimal exam of liver)
    • mild gallbladder wall thickening
  • 2022-08-22 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Segmental esophageal lesion, suspected advanced esophageal cancer, 22-30 cm below incisors, s/p biopsy
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
      • The examination was suboptimal due to patient’s intolerance
    • Suggestion
      • Pursue pathology result
      • CT scan is indicated

[consultation]

  • 2022-09-21 Hemato-Oncology
    • Q
      • This is a 55 year-old male, with underlying disease of (1) diabetes mellitus (2) hypertension. He suffered from dysphagia and odynophagia for one month. According to himself, he could swallow solid food, but there were foreign body sensation while food intake. No body weight loss, no fever, no cough. He then came to our gastrointestine clinic for help. Panendoscopy was done and and showed segmental esophageal lesion, further biopsy proven squamous cell carcinoma. Chest CT also done and revealed left lateral esophageal wall thickening with luminal narrowing at upper third of thoracic esophagus. Therefore, he was refferd to chest surgery clinic for further evaluation. After admission, we arranged PET, EUS, brain MRI, WBBS, bronchoscope and CPET for cancer work-up. On 2022-09-19, he underwent port-A insertion.
      • Impression: Upper thoracic esophageal cancer, cT2N2M0, Squamous cell carcinoma, moderately differentiated
      • We need to consult you for CCRT. Thanks a lot!
    • A
      • Impression:
        • Upper thoracic esophageal cancer, cT2N2M0, stageIII, Squamous cell carcinoma, moderately differentiated
        • Occult hepatitis B (anti Hbc positive)
      • Suggestion:
        • We will discuss with patient about CCRT, thanks for your referal
        • May arrange 24hr urine CCR and PTA auditory test
        • May arrange our OPD after discharge or transfer to our ward
        • If there is any problem, please feel free to let us known

[surgical operation]

  • 2022-12-12
    • Surgery
      • 3D VATS esophagectomy + gastric tube reconstruction.
    • Finding
      • One tumor was noted over U/3 of esophagus, s/p CCRT
      • One 24 Fr. straight chest tube was inserted via right 9th ICS.

[radiotherapy]

  • 2022-09-26 ~ undergoing? at 3240cGy/18 fractions of the esophageal tumor, peripheral including regional nodal area.

[chemoimmunotherapy]

Esophageal and Esophagogastric Junction Cancers, NCCN Evidence Blocks, 2022-09-07, Version 4.2022, ESOPH-F 5 OF 17, p49 = Principles of Systemic Therapy > Regimens and Dosing Schedules > Other Recommended Regimens

  • Fluorouracil and cisplatin
    • Cisplatin 75-100 mg/m2 IV on Days 1 and 29
    • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4 and 29-32
    • 35-day cycle

Administration

  • 2023-01-30 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
    • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg 10min] post cisplatin
  • 2022-10-21 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
    • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
  • 2022-09-26 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
    • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

==========

2023-01-31

  • Despite MgO PO, MgSO4 IV supplementation during hospitalization, this patient had several months of hypomagnesemia according to lab data. It is recommended that supplementation continue following discharge.

2022-10-25

  • The current two-drug cytotoxic regimen (fluorouracil + cisplatin) is preferred for patients with advanced disease because of lower toxicity.
  • The underlying conditions of hypertension, type 2 diabetes, hyperuricemia are well managed with patient-carried medications based on blood pressure, finger stick measurements and lab data.
  • Hypomagnesemia (1.4mg/dL 2022-10-24) is treated with MgSO4 injection.
  • The active prescription is not subject to any issues.

700999046

230131

[assessment]

  • In response to anemia (2023-01-27 HGB 7.5g/dL), LPRBC 2U was transfused on 2023-01-28 to treat the condition.

  • Cold hemagglutination was observed in 2023-01-27 lab data.

    • Cold agglutinins regularly occur during the course of two infections: 1. M. pneumoniae (primary atypical pneumonia), 2. Epstein-Barr virus (infectious mononucleosis). Case reports have described cold agglutinins in the setting of other viral infections such as HIV, rubella virus, influenza viruses, COVID-19 infection, or varicella-zoster virus (chickenpox). Not all individuals with these infections who develop cold agglutinins will have clinically significant hemolysis. For those who do, it usually occurs approximately two weeks after onset of the primary infection, diminishes as the infection begins to resolve, and is gone within two to three months.
    • Cold agglutinins have also been described in individuals with autoimmune disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis.

701431422

230130

[exam findings]

  • 2023-01-28 CXR
    • S/P pace-maker implantation.
    • Enlargement of right hilum.
    • Atherosclerosis of the aorta.
  • 2023-01-27 CT - abdomen
    • Indication:
      • He received pancreatic ca stage I operation (Nov. 2022) at VGH.
      • He was recommended to receive TS-1
      • Night fever was noted since Dec. 16, 2022.
      • Fever, nature ? (20230113)
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a lobulated cystic lesion with enhancing wall at left anterior subphrenic space, measuring 14 x 6 x 4 cm (width x depth x cranial-caudal length).
        • Pseudocyst is highly suspected.
        • The differential diagnosis include abscess.
        • please correlate with clinical condition.
      • There are two lobulated cystic lesion in right and left para-colic gutter space, measuring 1.9 x 2.6 x 3.2 cm and 1.7 x 2.3 x 3,8 cm, respectively.
        • Pseudocysts are highly suspected.
      • There is another cystic lesion with enhancing wall at the midline pelvis, measuring 5 x 4 cm.
        • Pseudocyst is also suspected.
      • There is ascites in right perihepatic space,
      • S/P Whipple operation and S/P cholecystectomy.
      • There is mild left Pleura effusion.
      • Others
        • There is no focal abnormality in the biliary system, spleen & both kidney.
        • There is no evidence of lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Pseudocyst (14 x 6 x 4 cm) in left anterior subphrenic space is highly suspected.
        • The differential diagnosis include abscess. please correlate with clinical condition.
      • Three lobulated cystic lesions in bilateral para-colic gutter space and midline pelvis are noted.
        • Pseudocysts are highly suspected.
  • 2023-01-16 ECG
    • Atrial-paced rhythm
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2023-01-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Scoliosis of the T-spine with convex to right side.

[assessment]

  • Despite having a pacemaker implanted, the patient’s heart rate doubled from 64 (2023-01-29 20:03) to 144 (2023-01-30 08:50).

  • Runaway pacemaker occurs when the pacemaker’s pulse generator discharges at a rate above its preset upper limit. The malfunction lies entirely within the pulse generator. It should be suspected if pacemaker dysrhythmias occur at rates greater than 130 beats/min or the upper rate limit if this is known. ref: Tachycardia in the presence of a pacemaker. Postgrad Med J. 2004;80(940):119-122. doi:10.1136/pmj.2002.004036q

701433000

230130

[lab data]

  • 2022-07-21 Anti-HBc Reactive
  • 2022-07-21 Anti-HBc-Value 7.05 S/CO
  • 2022-07-21 Anti-HBs 10.17 mIU/mL
  • 2022-07-21 Anti-HCV Nonreactive
  • 2022-07-21 Anti-HCV Value 0.07 S/CO

[exam findings]

  • 2023-01-28 Elbow LT
    • Left elbow X-ray shows
      • Permeative change of proximal radius is found. Fracture line is also found. Pathological fracture is considered.
      • Regional soft tissue swelling is identified.
  • 2023-01-28 KUB
    • Phlebolith at pelvic cavity is found.
  • 2023-01-28 CXR
    • Cardiomegaly is noted.
    • Nodular lesion at both lungs is found.
    • The trachea is deviated to right side is found.
  • 2023-01-16, -01-10 CXR
    • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
    • Borderline cardiomegaly
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Few nodular opacity projecting at both lung are noted that are c/w metastases after correlate with CT.
  • 2023-01-04 CT - chest
    • Findings - Comparison was made with previous CT dated on 20220624
      • Lungs:
        • multiple randomly distributed pulmonary nodules of varying sizes up to 26mm at RUL due to metastases.
        • septal thickening over medial Rt upper lobe.
      • Mediastinum and hila: resolution of M/3 esophageal tumor, with mild wall thickening.
        • extensive lymphadenopathy in the visceral space and left anterior prevascular space, with tracheal and thyroid gland invasion and encasing Ly common carotid artery
        • small pericardial effusion.
      • Pleura: minimal bilateral effusion.
      • Visible lower neck: metastatic LAPs in left deep cervical space,
      • Visible abdominal-pelvic contents:
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. no ascites.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • m/3 esophageal cancer with resolution of primary tumor but pogression of lung and distant LNs metastases compared with 2022-06-24
  • 2023-01-03 Neck Soft tissue X-rays
    • Swelling of prevertebral soft tissue at C4-6 level.
    • Straightening alignment of cervical spine.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-01-03 CXR
    • Pulmonary nodules at right lung.
  • 2022-10-26 Patho - lung transbronchial biopsy
    • Trachea, central, bronchoscopic biopsy —- acute and chronic inflammation — negative for malignancy
  • 2022-10-14, -09-21, -09-07, -09-01 CXR
    • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
    • Borderline cardiomegaly
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-08-25 CXR
    • No active lung lesion.
    • No cardiomegaly.
    • T-spine spondylosis.
  • 2022-08-17, -08-10, -08-03, -07-29 CXR
    • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2022-07-25 CXR
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Crowding of vascular markings over Rt lower lung zone
    • Displacement of the tracheal axis to right at thoracic inlet and superior mediastinum probably due to lymph node enlargement,
    • enlarged cardiac silhoutte
    • A tracheostomy tube in place, proper position
  • 2022-07-22 Patho - esophageal biopsy
    • Esophagus, upper, biopsy — Squamous cell carcinoma, poorly differentiated
    • Section shows several pieces of squamous mucosa with infiltration of nests of poorly differentiated tumor cells.
    • The immunohistochemical stain of p40 is positive.
  • 2022-07-22 Miniprobe endoscopic ultrasound
    • Endoscopic findings
      • A fungating ulcerative tumor mass with easily touched bleeding is seen at the upper to middle esophagus 20cm to 35cm below the incisors. Biopsy *8 are done. The scope cannot pass through this stenotic site.
    • EUS findings
      • EUS using miniprobe (Olympus UM-DP-25R) showed whole layer thickening with loss of stratification and invading the surrounding structure. The tumor size is about 15 cm in length. There are three hypoechoic LNs found outside the esophagus.
    • Diagnosis
      • Esophageal cancer, T3N2, s/p Bx
    • Suggestion
      • Pursue biopsy result
  • 2022-07-20, -07-18, -07-12 CXR
    • Crowding of vascular markings over both lower lung zones
    • Displacement of the tracheal axis to right at thoracic inlet and superior mediastinum probably due to lymph node enlargement,
    • enlarged cardiac silhoutte
    • A tracheostomy tube in place, proper position
  • 2022-07-15 Patho - esophageal biopsy
    • Labeled as “esophagus, 20 cm to 35 cm”, biopsy — squamous cell carcinoma, poorly differentiated.
    • IHC stains: CK5/6 (+), P40 (+), CDX2 (weak +), CD56 (-).
  • 2022-07-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal cancer, 20-35cm, s/p biopsy
      • Duodenal shallow ulcers, D1 to D2
      • Reflux esophagitis LA grade A
      • Superficial gastritis, s/p CLO test
    • Suggestion
      • Pursue results of pathology and CLO test
      • PPI use
  • 2022-07-13 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the skull, maxilla, mandible, T-spine, right clavicle bone, bilateral shoulders, S-I joints, and hips.
  • 2022-07-13 MRI - brain
    • no evidence of brain metastasis.
  • 2022-07-12 Whole body PET scan
    • A glucose hypermetabolic lesion involving middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in some confluent upper left paratracheal lymph nodes with possible invasion to adjacent trachea, two right paratracheal lymph nodes and a lymph node in the upper abdomen just between the stomach and left lobe liver. Metastatic lymph nodes may show this picture.
    • Mild glucose hypermetabolism in the right lower lung field. Inflammation may show this picture.
    • Increased FDG uptake in the right vocal cord. The nature is to be determined (inflammation? physiological FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake in bilateral neck muscles and mucles of anterior abdominal wall. Physiological FDG uptake is more likely.

[consultation]

  • 2023-01-28 Orthopedics
    • A
      • Pat Bas Info
        • 62y/o male
        • Past history: Squamous cell carcinoma of middle third esophageus, cT4N3M0 stage IVA s/p jejunostomy, left Port-A implantation and tracheostomy on 2022/07/12
        • Allergy: NKDA
        • No current anti-platelet/anti-coagulation medication usage
        • 169cm, 66.5kg
      • Subjective: left proximal forearm tenderness after lifting motorcycle 3 days ago
      • Physical examination:
        • Inspection: left proximal forearm: mild swelling, no ecchymosis, no open wound
        • Palpation: left proximal forearm tenderness, aggravated when motion (supination/pronation)
        • Motion: elbow supination/pronation(+ but tenderness); wrist flexion/extension(+); finger motion(+)
        • Distal sensation: intact
        • Circulation: Capillary refill time <2sec, radial pulse(+)
      • X-ray:
        • Left proximal radius radiolucent density and permeative change, consider pathological fracture
        • No evidence of destructive bone lesion found on KUB.
      • Previous exam
        • 2022/07/13 Tc-99m MDP whole body bone scan
          • No strong evidence of bone metastasis.
          • Suspected benign lesions in the skull, maxilla, mandible, T-spine, right clavicle bone, bilateral shoulders, S-I joints, and hips.
        • 2023/01/28 CXR
          • Nodular lesion at both lungs is found.
      • Plan:
        • Long arm splint and triangular sling immobilization
        • Adequate pain control
        • Please arrange Tc-99m MDP whole body bone scan.
        • Conservative management was recommended first.
        • OPD follow-up and arrange further treatment
  • 2022-07-21 Hemato-Oncology
    • Q
      • This 62-y/o male who denied any systemic disease was diagnosed with esophageal cancer this year.
      • Tracheostomy + Prot-A + Jejunotomy were performed on 2022/07/12, and brain MRI, whole body bone scan and PET scan were done.
      • His tumor staging was T4N3M0.
      • We would like to consult your expertise on arrangement of CCRT for the patient, thank you!
    • A
      • Impression:
        • Poorly differentiated Esophageal squamous cell carcinoma, with trachea compression and deviation cT4N3M0, s/p Tracheostomy + Prot-A + Jejunotomy were performed on 2022/07/12
        • Aspiration pneumonia
      • Suggestion:
        • CCRT is indicated in this case (PF4). Please check HbsAg, AntiHbc, Anti HCV. Arrange auditory PTA and 24 urin CCR

[surgical operation]

  • 2022-07-12 Feeding jejunostomy + port-A + tracheostomy

[radiotherapy]

  • 2022-07-29 ~ 2022-09-20 - 5040cGy/28 fractions of the esophageal tumor, peripheral involved, and regional lymphatic area.

[chemoimmunotherapy]

  • 2022-10-13 - cisplatin 80mg/m2 150mg 24hr D1 + fluorouracil 1000mg/m2 1900mg 24hr D1-4
  • 2022-09-14 - cisplatin 40mg/m2 75mg 2hr (CCRT)
  • 2022-09-07 - cisplatin 30mg/m2 60mg 2hr (CCRT)
  • 2022-08-17 - cisplatin 30mg/m2 60mg 2hr (CCRT)
  • 2022-08-10 - cisplatin 30mg/m2 50mg 2hr (CCRT)
  • 2022-08-05 - cisplatin 30mg/m2 50mg 2hr (CCRT)
  • 2022-07-29 - cisplatin 30mg/m2 50mg 2hr (CCRT)

==========

2023-01-30

  • When pulmonary symptoms limit the patient’s ventilation, oxygenation becomes more important.

  • Laboratory 2023-01-28: MCV 68.5fL, MCH 21.5pg, both below LLN since 2nd half 2022, there may be an iron deficiency. It is recommended that the patient’s body iron level be checked in order to determine whether iron supplements need to be added.

2022-10-14

  • There are no results for HER2 from the pathologies performed on 2022-07-22 and 2022-07-15. In the event that HER2 overexpression is confirmed, trastuzumab should be added to first-line chemotherapy. (NCCN 2022-09-07 version 4.2022)
  • The serum magnesium level has been no higher than 1.8mg/dL since 2022-08-05 (with oral MgO currently). Hypomagnesemia due to urinary magnesium wasting occurs in over one-half of cases of cisplatin-induced nephrotoxicity. It can occur without the presence of concomitant AKI. In patients who receive cisplatin for several months, urinary magnesium wasting may persist even after discontinuation of cisplatin therapy. In addition to its direct clinical manifestations, hypomagnesemia may exacerbate cisplatin toxicity. As always, please keep an eye on the related signs.
  • Hypokalemia (2022-10-13 3.1mmol/L) is managed with Radi-K (potassium gluconate) currently.
  • It is suggested a solution consisting of isotonic saline supplemented with KCl and MgSO4 rather than isotonic saline alone. Specifically, a solution consisting of 1000 mL of isotonic saline plus 20 mEq of KCl and 2 grams of MgSO4, and administer intravenously a minimum of 1000 mL of this solution over two to three hours prior to, and a minimum of 500 mL over the two hours following, the cisplatin administration. This fluid administration should be adequate to establish a urine flow of at least 100 mL/hour for two hours prior to, and two hours after, chemotherapy administration. The rationale for adding potassium and magnesium to the solution is to avoid the development of hypokalemia and hypomagnesemia that may occur with forced diuresis; in addition, magnesium supplementation may help to limit cisplatin nephrotoxicity. The addition of furosemide is generally not required, unless there is evidence of fluid overload. (ref: UpToDate https://www.uptodate.com/contents/cisplatin-nephrotoxicity )

700387653

230127

  • past history
    • Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT
    • HTN
    • Hyperurecemia
  • exam finding
    • 2022-11-01 MRI - nasopharynx
      • The current study was compared to the prior one obtained on 2022/06/14.
      • Known a case of right oropharyngeal cancer S/P CCRT. Marked regression of prior shown soft-palate and tonsillar lesions. But progression of right sphenoid sinus lesion and more invasion of right masticator space.
      • Focal subcortical edema of right temporal lobe tip with abnormal enhancement, may be due to radiation necrosis. But direct invasion by adjacent tumor can not be ruled out. Suggest follow up.
      • Right-sided paranasal sinusitis.
      • Right otitis media and mastoiditis.
    • 2022-10-26 CT - abdomen
      • History: oropharyngeal cancer diagnosed in Mackey asked for further opinion and management
        • 2022-05-31 biopsy over right oropharynx (soft plate) MacKay Memorial Hospital: SCC
      • Findings:
        • There is mild dilatation of IHDs, CHD, and CBD.
          • Please correlate with serum alk-p and bilirubin level.
        • There is mild dilatation of the pancreatic duct and it seems directly drained into minor papilla.
          • Please correlate with MRCP to R/O pancreatic divisum.
        • There are few enhancing nodules on right hepatic lobe at arterial phase images but isodensity in portal venous phase and delayed phase images.
          • Spontaneous arterio-portal shunting are highly suspected.
          • Please correlate with sonography and MRI.
        • There is a newly-developed lobulated poor enhancing soft tissue mass measuring 3.5 cm in left hilum.
          • Metastasis is highly suspected.
        • S/P nasogastric tube insertion
        • Fecal material store in the colon.
      • Impression:
        • There is mild dilatation of IHDs, CHD, and CBD. Please correlate with serum alk-p and bilirubin level.
        • There is mild dilatation of the pancreatic duct and it seems directly drained into minor papilla. Please correlate with MRCP to R/O pancreatic divisum.
        • There are few enhancing nodules on right hepatic lobe at arterial phase images but isodensity in portal venous phase and delayed phase images. Spontaneous arterio-portal shunting are highly suspected. Please correlate with sonography and MRI.
        • There is a newly-developed lobulated poor enhancing soft tissue mass measuring 3.5 cm in left hilum. Metastasis is highly suspected.
    • 2022-09-09 CXR
      • Tortous aorta with calcification is noted.
    • 2022-09-09 ECG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2022-08-27 CXR
      • S/P NG tube indwelling.
      • S/P Port-A infusion catheter insertion.
      • Ground glass opacity in LLL.
    • 2022-08-24 CXR
      • S/P port-A implantation.
      • S/P nasogastric tube insertion
      • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
    • 2022-08-13 CXR
      • Consolidation in left lower lung, stationary.
    • 2022-08-10 CXR
      • S/P port-A implantation.
      • S/P nasogastric tube insertion
      • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
    • 2022-08-03 Nasopharyngoscopy
      • Findings
        • Left nasal floor Tumor seen, partial obstruction,
        • NP smooth
        • PND+
        • Oropharynx partial occlusion by tumor
        • Bil vocal cord good motility, no paresis
        • Bil parapharyngeal wall tumor involvement
        • No saliva pooling in bil pyriform sinus
        • Vallecula/tongue base patent
        • NG in place
      • Conclusion:
        • orophayrngeal SqCC p16(+) cT4N0M0 Stage II under CCRT
        • OPD f/u
    • 2022-07-26 CXR
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
    • 2022-07-21 CXR
      • Patchy consolidations at LUL-lingula and LLL due to pneumonia with pleural effusion still visualized
      • Thoracic aortic arch calcified atheriosclerotic plaque
    • 2022-07-20 Bronchoscopy
      • symptom:
        • dyspnea with much sticky sputum
      • clinical diagnosis:
        • SCC of the oropharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT, LLL pneumonia with much sputum
      • bronchoscopic diagnosis
        • Bronchitis, LLL, with pus like sputum over LLL bronchus and emerging from distal airway
    • 2022-07-16 CT - lung
      • LML and LLL consolidations, suspected pneumonia
      • A faint ehancing nodule(0.5cm) in S6 of liver. Suggest sonography correlation.
    • 2022-07-16 ECG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2022-07-16 CXR
      • Consolidation in left lung
    • 2022-06-15 Tc-99m MDP whole body bone scan
        1. A hot spot in the left 1st rib, probably normal variant, post-traumatic change, or other benign nature. Please keep follow-up for further evaluation.
        1. Probably benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
    • 2022-06-14 MRI - nasopharynx
      • AJCC 8th edition Staging status: T4bN0M0
    • 2022-06-14 Patho - esophageal biopsy
      • A: Esophagus, lower, near EG junction, biopsy — Compatible with Barrett’s esophagus
      • B: Esophagus, upper, biopsy — Compatible with heterotopic gastric mucosa
    • 2022-06-13 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal mucosal lesion, lower esophagus near EG junction, suspected to be secondary mucosal change due to reflux esophagitis or heterotopic gastric mucosa; s/p biopsy (A)
        • Esophageal mucosal lesion, esophageal inlet, probable heterotopic gastric mucosa; s/p biopsy (B)
        • Superficial gastritis
        • Oropharyngeal cancer
      • Suggestion
        • No endoscopic evidence of metachronous esophageal cancer
        • Pursue biopsy result
    • 2022-06-09 Nasopharyngoscopy
      • orophayngeal tumor involved bil. tonsils, soft palate with right soft palate perforation tongue base, hypopharynx, larynx: ok
    • 2022-05-31 Pathology (at Mackey Hospital)
      • Oropharynx, soft palate, right side, biopsy, squamous cell carcinoma.
      • The result of immunohistochemical study with p16 is positive for tumor cells.
      • Dr. DongYing Chen has reviewed the lesion slide and concurs with the diagnosis of carcinoma.
  • consultation
    • 2022-08-31 Dermatology
      • Q
        • This 56-year-old man patient is a case of squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0, stage III s/p concurrent chemoradiotherapy. This time, for upper and lower limbs skin itch without redness rash. Now, for evaluate skin itch therapy. Thank you.
      • A
        • The patient had sufferred from SCC under chemoradiotherapy. Erythematous itchy papules with excoriative crust on the four limbs and turnk for days.
        • Under the impression of eczema with post-scretch wound and prurigo formation.
        • The following sugeetion:
          • Betason-N onit 3 tube topical bid use on the excoriative wound first
          • Topysm cream 2 tube topical bid use on the reddish itchy papule lesions.
          • add Cypromin lotion 10cc QID po for pruritus control.
    • 2022-07-28 Rehabilitation
      • Q
        • This 56 year-old man patient is a care of Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0, stage III s/p concurrent chemoradiotherapy. This time, for being unable to open mouth. Now, for evaluate mouth rehabilitation. Thank you.
      • A
        • This is a 56 y/o male patient with history of
            1. Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT
          • 2.) Hypertension
          • 3.) Hyperurecemia under medication control.
        • He was regular F/U at our oncologist OPD.He was just discharge form our ENT ward on 2022-06-16.
        • PE
          • Consciousness: E4V5M6
          • Cognition:could follow orders
          • Speech: no aphasia
          • Swallowing: NG (+)
          • limited mouth and tongue ROM
          • Functional status: could ambulates with CG
          • BADL: needs max assistance (NG +
        • Assessment
          • Squamous cell carcinoma of the orpharynx, p16(+),
        • Plan
          • Lip-mouth movement instruction
    • 2022-06-14 Oral and Maxillofacial Surgery
      • Q
        • This 56 y/o male patient with history of HTN and hyperurecemia under medication control. This time, he went to our hospital due to progressive sore throat for 1 year and dysphagia for 6 months. Poor appetite and weight loss 10 kg in 6 months were also noted. Intermittent headache was also complained. Due to odynophagia and dysphagia progressed, he went to Mackey Hospital for help.
        • Biopsy for right soft palate was done, and the pathology was SCC, P16 (+). He went to our ENT OPD for second opinion and further management. At Dr. Su’s OPD, Nasopharyngoscopy showed orophayngeal tumor involved bil. tonsils, soft palate with right soft palate perforation. Tongue base, hypopharynx, larynx were grossly normal. PE showed no obvious lymphadenopathy. Admission for cancer work-up was suggested, and the patient and family agreed after well explanation. Under the impression of oropharyngeal cancer, P16 (+). the patient was admitted to ENT ward for cancer work-up. We need your help for pre-CCRT dental evaluation and management. Thank you very much!!
      • A
        • This is a 56 y/o male who suffured from SCC of orophayngeal regioninvolved bil. tonsils, soft palate with right soft palate perforation. and is about to received radiotherapy.
        • O:
            1. Hopeless tooth 17 and 38 were noted.
            1. Chronic gingivitis of full mouth was noted.
            1. Poor oral hygiene was noted.
        • P:
            1. Take panoramin film for tooth evaluation
            1. Suggest extraction of tooth 17 and 38.
            1. OHI (oral hygiene instruction)
  • radiotherapy
    • 2022-07-13 ~ - 4400cGy/22 fractions of the oropharyngeal to nasopharyngeal tumor, peripheral involved, to bilateral neck.
  • chemoimmunotherapy
    • 2022-09-22 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-24 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-17 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-10 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-03 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-07-13 - cisplatin 40mg/m2 65mg 2hr (CCRT)

==========

2023-01-27

[tube feeding, drug interactions]

  • Scrat (sucralfate) should be administered on an empty stomach. Please shake suspension well before use and do not administer antacids within 30 minutes of administration of sucralfate. In general, it is recommended to separate administration of other oral medications and sucralfate by at least 2 hours. With Panzolec (pantoprazole) 40mg IVD QD (09:00) and Scrat 1g PO Q6H (05:00, 11:00, 17:00, 23:00), it should be less likely that there will be obvious interactions between the two. The adjustment does not need to be made.

  • Bromelain, the main active ingredient in Broen-C tablets, is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. The drug is therefore designed to be enteric coated. There is no alternative for this ingredient available in the hospital at present time.

2023-01-22

Management of vasogenic edema in patients with primary and metastatic brain tumors - glucocorticoids - ref: https://www.uptodate.com/contents/management-of-vasogenic-edema-in-patients-with-primary-and-metastatic-brain-tumors

  • 2023-01-11 brain MRI showed increased heterogeneous soft tissue enhacement in the right temporal lobe and right cavernous sinus with right cavernous ICA encasement. suspected radiation necrosis or tumors.

  • Systemic glucocorticoids are the mainstay of symptomatic therapy for peritumoral edema. They play a role in stabilizing patients awaiting definitive treatment of the tumor as well as in palliative management of edema related to treatment-refractory tumors.

  • Emergency management of increased ICP

    • A significant increase in intracranial pressure (ICP) causing drowsiness and other signs of impending herniation can be a medical emergency, and treatment should be undertaken as expeditiously as possible, typically in an intensive care unit setting. A bolus dose of dexamethasone (eg, 10 mg IV) should be given acutely, followed by 16 mg/day in divided doses. Doses as high as 40 mg/day may be given in the emergency setting for brain tumor-related edema and mass effect. Additional interventions during the first 24 to 72 hours may be required to lower ICP, such as hypertonic saline and mannitol.
  • Initiation of glucocorticoids

    • Systemic glucocorticoids should be considered in all patients who have symptomatic peritumoral edema. Depending on the location of the tumor and the extent of edema, symptoms may be generalized (eg, headache, nausea, vomiting) or focal (eg, aphasia, hemiparesis), or both.
    • Dexamethasone is the standard agent for peritumoral edema management because its high potency and relative lack of mineralocorticoid activity reduce the potential for fluid retention [15-17]. In addition, dexamethasone can be given orally or intravenously (IV) with a 1:1 conversion ratio.
    • For patients requiring low to moderate amounts of dexamethasone (eg, 4 to 6 mg daily or less), prednisone is sometimes used as an alternative to dexamethasone in patients with steroid myopathy or in those with a history of adrenal insufficiency, as it allows for a taper in smaller increments.
  • Dexamethasone dose and schedule

    • The antiedema effects of dexamethasone are dose dependent, and the starting dose should be individualized based on the extent of edema and the severity of symptoms [16,18,19]. Because most side effects are also dose dependent, the goal is always to use the lowest dose necessary to control symptoms.
      • In patients with moderate to severe symptoms (eg, severe headache, nausea and vomiting, significant focal neurologic deficits), the usual initial dexamethasone regimen consists of a 10 mg loading dose IV, followed by an initial maintenance dose of 8 to 16 mg daily in divided doses orally (or IV for patients not tolerating oral medications).
      • For patients with milder symptoms, a loading dose is usually omitted, and smaller total daily doses (eg, 2 to 4 mg divided once or twice daily) are usually adequate and less toxic.
      • Most patients who are asymptomatic do not require steroids, although clinical judgment is required in patients with large amounts of edema, particularly when antitumor therapy has the potential to worsen edema. Increased caution is also required for posterior fossa tumors and edema, which can be associated with rapid deterioration.
    • Although it has been customary to administer dexamethasone in four divided daily doses, its biologic half-life is sufficiently long (36 to 54 hours) to allow once- or twice-daily dosing, and this approach is preferred for maintenance therapy because it is easier for patients and has not been associated with diminished efficacy. We use once-daily morning dosing when possible and avoid late evening and middle-of-the-night dosing to help reduce insomnia caused by glucocorticoids. To minimize complications, subsequent dosing should be modified to use the lowest possible dose necessary to control peritumoral edema. (See ‘Complications and prophylaxis’ below and ‘Approach to taper’ below.)
    • Absorption of oral dexamethasone is excellent and is complete within 30 minutes of administration. Oral and IV dosing is equivalent. IV dosing may be necessary if oral absorption cannot be assured, or if oral intake is unsafe due to altered mentation or other deficits.
  • Response assessment

    • Management of peritumoral edema is largely empiric. Clinical response, rather than radiographic changes, should guide most decisions.
    • Most patients begin to improve symptomatically within hours and achieve a maximum benefit from a given dose of dexamethasone within 24 to 72 hours. In general, headaches tend to respond better and more quickly than focal deficits, in part because edema may not be the only cause of focal deficits. The maximum neuroimaging response lags behind clinical response by days to a week or two.
  • Inadequate response to initial dose

    • When patients fail to improve or improve only partially after several days on the initial dose, there are two main possibilities. Either a higher dose is required, or the residual symptoms are caused by factors other than peritumoral edema.
    • A trial-and-error strategy is often used to help distinguish between the two. For patients on submaximal doses, the dexamethasone dose is typically doubled for two to three days as a trial (usual maximum total daily dose, 16 mg). If the patient improves clinically, the higher dose is continued. The less a patient responds to a doubling of the dose, the less likely it is that symptoms are steroid responsive. If there is no response by 72 hours, the dose can generally be returned to the previous dose level without taper. This strategy helps to avoid excessive steroid dosing and toxicity in the absence of clinical benefit.
    • If a dexamethasone dose of 16 mg per day is insufficient, the dose may be increased further, although often with diminishing returns and excess toxicity. Alternative options for refractory edema should be considered in such cases.
  • Approach to taper

    • Once patients have responded and stabilized clinically on a given dose of dexamethasone, a gradual taper should be attempted, if possible. This is particularly important for patients on high initial doses of dexamethasone (eg, >8 mg daily), as weight gain and proximal weakness often emerge within weeks at such doses. The likelihood of success and the speed of the taper depend on multiple factors, including the status of the underlying tumor, concurrent therapies, and the duration of steroid therapy. Postoperative steroid tapers in patients who have undergone complete tumor resection can be relatively rapid, for example, whereas efforts to taper steroids in patients with residual or progressive tumors must be approached more cautiously.
    • Dexamethasone has a long duration of action, and therefore a period of at least three to four days should generally follow each dose decrement to establish clinical tolerance of the lower dose. For patients in good clinical condition whose tumor has been stabilized with recent treatment, a taper may entail a reduction in dose of up to 50 percent every four days. A more protracted taper and chronic treatment may be required for patients with active tumors and those who do not tolerate initial attempts to wean steroids. Patients and caregivers should be educated about signs and symptoms that may signal reaccumulation of symptomatic edema as dexamethasone is being tapered (ie, recurrent or worsening headaches, focal deficits).
    • Symptoms not caused by recurrence of brain edema may develop during the course of the steroid taper (steroid withdrawal syndrome). These include mild headache and lethargy that may mimic recurrence of brain edema as well as myalgias and arthralgias (steroid pseudorheumatism). All of the symptoms respond to raising the dose slightly and tapering more slowly.
  • Refractory edema

    • Management of chronic, symptomatic edema can be challenging. Many patients develop toxicities related to chronic glucocorticoids, which in some cases eventually outweigh the benefits. Surgical debulking of the associated tumor may be indicated in select cases, even when the goal is not curative, in order to help control the underlying cause of the edema. For certain tumor histologies, bevacizumab may be an option to help control edema. If globally elevated ICP is the main source of refractory headaches or symptomatic plateau waves, ventricular shunting may be an option in some patients.
    • Role of bevacizumab
      • Since vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of peritumoral edema, anti-VEGF monoclonal antibodies such as bevacizumab or inhibitors of VEGF receptors are useful in reducing edema. The steroid-sparing effects of bevacizumab were demonstrated in a randomized phase II study of bevacizumab with or without irinotecan in patients with recurrent glioblastoma, in which 30 to 50 percent of patients had a sustained reduction in glucocorticoid dose and approximately 20 percent achieved a complete taper. Other VEGF inhibitors have shown similar effects.
      • In patients with recurrent/refractory glioblastoma and symptomatic peritumoral edema, the clinical antiedema effects of bevacizumab can often be observed within days of the first dose. This effect tends to be persistent with ongoing therapy and can improve the likelihood of a successful dexamethasone taper.
      • Bevacizumab also finds selective use in the management of edema related to radiation necrosis.
  • Symptomatic plateau waves

    • Plateau waves are sustained pressure waves that normally occur within the brain and are caused by activities that transiently raise the ICP (eg, standing, sneezing, coughing). In the presence of a brain tumor, significant further increases in ICP can temporarily cut off cerebral perfusion, leading to loss of consciousness. The treatment of choice for such cases is glucocorticoids and neurosurgical intervention for cerebrospinal fluid (CSF) diversion, when appropriate.

2022-11-10

  • The level of SCC was high (2022-11-09 5.1 ng/mL) during the last half year.
  • According to 2022-11-01 MRI and 2022-10-26 CT, the disease has regressed in some areas while progressing in others. It appears to be heterogeneous, increasing the possibility of resistance.
  • As far as the active prescription is concerned, there is no problem.

2022-09-12

  • It is possible that this patient will require a transfusion of LPRBC due to HGB 6.7g/dL on 2022-09-12.
  • Newly developed oral candidiasis has been promptly managed with Mycostatin oral suspension (nystatin). The erythematous itchy papules that developed at the end of August 2022 are currently being treated with Cypromin (cyproheptadine).
  • Blood culture and urine culture were performed on 2022-09-09, but the results have not yet been released. Tapimycin (piperacillin + tazobactam) has been used as an empiric antibiotic since then.
  • Tube Feeding
    • Broen-C (bromelain + L-cysteine) is an enteric coated tablet and is not intended for use with a nasogastric tube. As of right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

2022-08-29

  • It is not recommended that Broen-C is peel-halfed or ground because it is enteric-coated.
  • There was a drop in blood pressure to 98/63 (2022-08-29 16:23), which should be noted.

701320382

230127

{drug interactions}

  • Pantoprazole prescribing information states no clopidogrel dose adjustments are required during coadministration with an approved dose of pantoprazole.

700412091

230119

[exam findings]

  • 2023-01-18 MRA - brain
    • Indication: The patient said that he started to have blurred vision an hour ago, numbness in his left hand and left face, and he had this once before, a small stroke.
    • IMP: Moyamoya disease. Acute infarct in right occipital lobe.
  • 2023-01-18 CT - brain
    • Indication: The patient said that he started to have blurred vision an hour ago, numbness in his left hand and left face, and he had this once before, a small stroke.
    • Findings
      • Small calcifications in pineal gland.
      • A small calcificaiton focus at left VA.
    • IMP: No evidence of intracranial lesion.
  • 2022-10-04 MRA - brain
    • Findings:
      • Focal subacute ischemic infarct over right posterior corona radiata (posterior water-shed area).
      • Old ischemic infarcts over both corona radiata (water-shed areas).
      • Engorgement of leptomeningeal vessels.
      • Total occlusion of right MCA and both ACAs. Near-total occlusion of left MCA. Markedly decreased flow of both MCA & ACA branches. Suggest check cerebral angiography.
      • Normal appearance of paranasal sinuses.
      • Normal appearance of both mastoids.
  • 2022-10-03 Neurosonology
    • Mild to moderate stenosis in right CCA bifurcation (35.8% stenosis).
    • Minimal atherosclerosis in right proximal ICA and ECA.
    • Smaller caliber with decreased flow in right VA, indicating possible right VA hypoplasia; adequate total VA flow.
    • Normal extracranial carotid, and intracranial cerebral, vertebral, basilar arterial flows.
  • 2022-09-11 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Prolonged QT
  • 2022-09-11 CT - brain
    • Findings
      • Low attenuation in right parietal region.
      • A retention cyst (2.1cm) in left maxillary sinus.
      • Degeneration and spondylosis of C-spine.
    • IMP:
      • Low attenuation in right parietal region.
  • 2022-08-30 C-spine AP and Lateral
    • Degeneration and spondylosis of C-spine.
  • 2017-09-15 KUB
    • Degeneration of bony structures.

701008324

230118

[tube feeding]

  • Harnalidge (tamsulosin, designed for extended release) 0.4mg PO QDAC should be replaced by Urief (silodosin) 8mg PO QD for tube feeding.

  • Concor (bisoprolol 5mg/tab) package insert recommends swallowing the medication with some liquid and not chewing it. For tube feeding, the simple suspension method (SSM) involves suspending tablets and capsules in warm water for decay and suspension prior to administration, which can be applied to the Concor tablets.

700754253

230116

{High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1}

  • diagnosis
    • 2022-08-31 admission
        1. Diffuse large B-cell lymphoma, unspecified site
        1. Pericardial effusion (noninflammatory)
        1. Essential (primary) hypertension
        1. Type 2 diabetes mellitus without complications
  • past history
    • diseases
      • Hypertension for more years with medication control
      • Type II diabetes mellitus with OHA control,
      • Hypertensive cardiovascular disease.
    • surgical operation
      • HIVD s/p op on 202201
  • family history
    • Mother: HTN, DM
    • No cancer history
  • exam finding
    • 2023-01-13 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-11-29 CT - abdomen
      • Moderate regression of prior seen lymphoma in paraaortic region as compare with CT study on 2022-07-26.
      • Suspected uterine myomas.
      • Prominent soft tissue densities along bilateral ovarian veins, varices or prominent lymph nodes? Suggest follow up.
    • 2022-11-26 ENT Hearing Test
      • Tymp RE type C, LE type A
      • ART bil absent
      • PTA:
        • Reliability FAIR
        • Average RE 58 dB HL, LE 53 dB HL
        • RE mild to moderately severe SNHL (sensory neural hearing loss)
        • LE normal to moderately seevre SNHL
      • SRT (speech recognition threshold)
        • RE 45 dB HL
        • LE 35 dB HL
      • WDS
        • RE 88 % at MCL
        • LE 92 % at MCL
    • 2022-10-26 ECG
      • Sinus tachycardia
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-08-22 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (99.3 - 45.8) / 99.3 = 53.88%
        1. Normal AV/MV with no MR
        1. Concentric LVH, norma lLV wall motion
        1. Preserved LV and RV systolic function
        1. Mild PR, mild TR, normal IVC size
        1. Thickened peri-cardial fat
    • 2022-08-12 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-08-12 CXR
      • Enlargement of cardiac silhouette.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-08-05 Patho - peritoneum biopsy
      • Lymph node, retroperitoneum, CT-guide needle biopsy — High grade B-cell lymphoma
      • Sections show lymphoid tissue with infiltration of medium-size, monoclonal lymphocytes. Marked apoptosis and some small granulomas are seen.
      • The immunohistochemical stains reval CD3(-), CD20(+), CD10(+), BCL6(+), BCL2(-), Cyclin D1(-), cMYC(-), and MUM1(-). The Ki-67 is nearly 100%. The PAS and AFB special stains are negative.
    • 2022-08-04 Whole body PET scan
        1. The FDG PET findings are compatible with lymphoma involving multiple lymph nodes in the abdomen (on one side of the diaphragm).
        1. Mildly increased FDG uptake in the regions about the pericardium and pleura of left lower lung field. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
        1. Increased FDG uptake in a focal area in the left aspect of mandible. Dental problem may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
        1. Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
    • 2022-08-03 CXR
      • Cardiomegaly is noted.
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
      • Left pleural effusion is found.
      • There is no evidence of destructive bone lesion.
    • 2022-08-01 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • Left pleural effusion is found.
    • 2022-07-28 CXR
      • Cardiomegaly is noted.
      • S/p central line catheter placement with its tip at Superior vena cava.
      • s/p chest tube placement at left hemithorax.
      • Increased pulmonary vasculature is found.
      • Faint aveolar opacity over LEFT LOWER LOBE is found.
    • 2022-07-27 Cell block
      • Positive for malignancy, compatible with malignant B-cell lymphoma
      • The smears and cell block show lymphocytes, reactive mesothelial cells and atypical individual lymphoid cells with enlarged nuclei, nucleoli and degenerative quality. Immunocytochemistry shows CK(-), CD20(+), CD3(-), Bcl-2(+, focal) and calretinin(-) for atypical cells.
      • According to cytomorphologic findings, it is compatible with B-cell lymphoma. Clinical correlation and confirmatory biopsy is advised for further evaluation.
      • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
    • 2022-07-27 CXR
      • Cardiomegaly is noted.
      • Status post endotracheal tube placement.
      • S/p central line catheter placement with its tip at Superior vena cava.
      • s/p chest tube placement with its tip at left hemithorax.
      • Increased pulmonary vasculature is found.
      • Faint aveolar opacity over right lower lobe and left lower lobe is found.
    • 2022-07-26 CTA - chest
      • Enlarged LNs (up to 3.6cm) at retroperitoneum.
      • Pericardial effusion.
    • 2021-12-23 SONO - kidney
      • CC: left flank pain
      • DX: left hydronephrosis
    • 2021-12-18 CT - abdomen, pelvis
      • Left lower ureter stones (up to 6.3mm) with obstructive uropathy. Grade 4 fatty liver.
    • 2021-11-23 Colonoscopy
      • Diagnosis
        • Colon polyp, transverse colon, s/p forcep polypectomy.
        • Mixed hemorrhoid
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
  • consultation
    • 2022-12-09 Infectous Disease
      • Q
        • Chest film disclosed Faint aveolar opacity over Right lower lobe is found. Patent airway is found.
        • MTB Infection Report showed Indeterminate,pending for PJP and Aspergillus Ag
      • A
        • CxR film showed no pneumonia.
        • IGRA inderterminate report.
        • Aspergillus Ag negative.
        • Recheck IGRA 3-4 months later.
    • 2022-11-16 Colorectal Surgery
      • Q
        • she complained of anal pain and fever also noted, highly suspect anal abscess, we need your expertise for further management        
      • A
        • S
          • The patient was consulted CRS for anal pain for weeks. No anal bleeding
          • She has the diagnosis of High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
        • O
          • Abdomen: soft, no tenderness, no distended
          • DRE: no palpable mass, no tenderness, no abscess or fistula, no fissure or ulcer
          • Mixed hemorrhoids(+), mild-moderate without thrombus
        • A: Mixed hemorrhoids
        • P:
          • Alcos-anal oint bid use, Proctosedyl 1# supp HS for 2 weeks
          • Consider sigmoidoscopy if still anal pain or “rectal pain”
          • No surgical indication at present
          • Suggest CRS OPD follow-up
    • 2022-11-01 Infectious Disease
      • Q
        • Lab data showed WBC 240, CRP 3.76. Chest x-ray showed increased denisty in the left lower lung field. Under the impression of neutropenic fever, chemotherapy related she was admitted for further evaluation and treatment.    
        • After admission, empiric antibiotics with Cefepime and targocid was administered but fever with occasionally chills was still noted. the blood culture yielded Corynebacterium spp.
        • We need your expertise for antibiotics evaluation, thanks
      • A
        • This is a case of high grade B-cell lymphoma s/p C/T.
        • WBC: 2960/uL
        • Corynebacterium spp. in blood culture might be contamination.
        • Suggestion:
          • Please collect B/C when fever
          • Check CMV PCR, sputum PjP PCR, sputum culture and sputum TB culture/AFB stain
          • Agree with your current use of imipenem and targocid
          • Please adjust antibiotic according to culture results and clinical conditions.
    • 2022-08-04 Radiological Diagnosis
      • Q
        • A case of B-cell lymphoma of pericardial effusion,CK(-), CD20(+), CD3(-), Bcl-2(+,focal) and calretinin(-).
        • CT of chest to abdomen showed enlarged LNs (up to 3.6cm) at retroperitoneum.
        • we need your expertise for CT guide biopsy,thanks
      • A
        • According to the clinical condition and imaging findings, biopsy is indicated.
    • 2022-08-02 Hemato-Oncology
      • Q
        • This 71 year old female with HTN, dyslipidemia, and DM was within her usual healthy state till 2~3 weeks ago c/o progressive SOB, and DOE.
        • CT showed large amount of bloody pericardial effusion, impending cardiac tamponade. s/p urgent PP window. The effusion appeared bloody pattern, and also intra-op TEE showed there is a ill-defined mass around the RA.
        • CT showed a enlarged LN over retroperitoneal space.
        • cell block showed Malignant b cell lymphoma.
        • Therefore, we need your expertise to guide us for further treatment and workup
      • A
        • The 71 year old female presented with pericardial effusion with impendiac cardiac tamponade post PP window. The effusion cell block revealed B cell lymphoma. Imaging study also revealed enlarged LN over retroperitoneal space and ill-defined mass aroud RA were noted also.
        • Comorbidity: with HTN, dyslipidemia, and DM.
        • Please arrange port-A for her and I can take over this case for further study and treatment.
        • Thank you for your referral.
    • 2022-07-29 Rehabilitation
      • A
        • Assessment
          • Pericardial effusion post PP window on 20220726
        • Plan
          • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs + coach training
          • Goal: recondition, improve endurance and muscle strength
          • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
    • 2022-07-26 Cardiac Surgery
      • A
        • for opinion regarding treatment options for large amount of pericardial effusion referered from OSH.
        • impending tamponade.
        • Previous Hx: HTN dyslipidemia, DM
        • CXR showed enlarged heart. compared to her CXR in 2021/12 there is significant interval change.
        • CT reviewed, showed large amount of pericardial effusion, heterogenous, suspect old hematoma? cause TBD.
        • also reported there is a enlarged LN at retroperitoneal space
        • S/S wise, she c/o progressive DOE during the past 2 weeks. and after previous trip 2 days ago, significant limitation of exercise was noted. and also reported decreased urine output.
        • LAB: WNL, no anemia,
        • SUGGESTION & PLAN:
          • I think we have reached a point where there is prudence in considering surgical intervention, PP window, given her developing symptoms.
          • PP window will be arranged. specimen will be sent for full workup. (pericardial-pleural window, PP window)
          • TEE (Transesophageal echocardiography, TEE)
          • SICU admission.
        • The patient and family are agreeable with my surgical consultation.
  • surgical operation
    • 2022-07-26 PP window via left minithoracotomy
      • pre-op CT and TEE showed large amount of pericardial effusion, also TEE found a heterogenous mass lying over RA, ~5cm in size.
      • 600cc bloody pericardial effusion was drained.
  • chemoimmunotherapy
    • 2023-01-05 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-12-12 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-10-17 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-09-22 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-08-31 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-08-10 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 ( vincristine not available then ) + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • G-CSF
    • Granocyte (lenogastin) CGRAN01
      • 2023-01-12 250ug QD SC D1-4 OPD
      • 2022-12-23 250ug QD SC D1-4 OPD
      • 2022-12-19 250ug QD SC D1-4 OPD
      • 2022-12-15 250ug QD SC D1-3 IPD 2022-12-08
      • 2022-10-20 250ug QD SC D1-3 IPD 2022-10-16
      • 2022-09-25 250ug QD SC D1-3 IPD 2022-09-22
      • 2022-09-09 250ug QD SC D1-3 OPD
      • 2022-08-22 250ug QD SC D1-3 OPD
    • G-CSF (filgrastim) CGCSF01
      • 2023-01-13 300ug QD SC D1-14 IPD
      • 2022-10-26 150ug ST SC IPD
      • 2022-10-26 150ug ST SC OPD
  • WBC
    • 2023-01-16 WBC 1.44 *10^3/uL
    • 2023-01-15 WBC 0.75 *10^3/uL
    • 2023-01-13 WBC 0.23 *10^3/uL
    • 2023-01-12 WBC 0.77 *10^3/uL
    • 2023-01-05 WBC 3.73 *10^3/uL
    • 2022-12-27 WBC 8.58 *10^3/uL
    • 2022-12-23 WBC 0.57 *10^3/uL
    • 2022-12-19 WBC 5.03 *10^3/uL
    • 2022-12-08 WBC 6.85 *10^3/uL
    • 2022-11-25 WBC 3.93 *10^3/uL
    • 2022-11-13 WBC 6.81 *10^3/uL
    • 2022-11-07 WBC 5.83 *10^3/uL
    • 2022-11-02 WBC 10.65 *10^3/uL
    • 2022-10-31 WBC 2.96 *10^3/uL
    • 2022-10-28 WBC 0.99 *10^3/uL
    • 2022-10-27 WBC 0.34 *10^3/uL
    • 2022-10-26 WBC 0.24 *10^3/uL
    • 2022-10-24 WBC 7.69 *10^3/uL
    • 2022-10-16 WBC 4.35 *10^3/uL
    • 2022-09-29 WBC 4.94 *10^3/uL
    • 2022-09-22 WBC 4.27 *10^3/uL
    • 2022-09-16 WBC 3.51 *10^3/uL
    • 2022-09-09 WBC 2.77 *10^3/uL
    • 2022-08-31 WBC 4.90 *10^3/uL
    • 2022-08-26 WBC 11.19 *10^3/uL
    • 2022-08-22 WBC 1.08 *10^3/uL
    • 2022-08-12 WBC 12.86 *10^3/uL
    • 2022-08-04 WBC 6.85 *10^3/uL
    • 2022-08-01 WBC 6.70 *10^3/uL
    • 2022-07-27 WBC 14.02 *10^3/uL
    • 2022-07-26 WBC 9.53 *10^3/uL
    • 2021-12-23 WBC 5.62 *10^3/uL
    • 2021-12-18 WBC 8.24 *10^3/uL
    • 2019-05-26 WBC 7.41 *10^3/uL

==========

2023-01-16

  • In late October 2022 and mid-Jan 2023, grade 4 neutropenia occurred approximately between 1-2 weeks after the patient’s receiving R-CHOP. As soon as neutropenia is identified, filgrastim and/or lenogastin has been appropriatedly administered. The WBC count returned to 1440 cells/uL on 2023-01-16.

  • Following a peak of 220mg/dL (2023-01-14 17:00), the patient’s serum glucose level returned to 114mg/dL (2023-01-16 05:17). It is not necessary to modify the patient’s antihyperglycemic agent immediately.

  • To treat neutropenic fever in this patient with hematologic malignancy, it is recommended to initialize an antipseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem, or piperacillin-tazobactam. Since 2023-01-13, cefepime 2000mg IVD Q8H has been used.

  • Since the culture result has not been released, teicoplanin 600 mg IVD QD and fluconazole 300 mg PO QD have also been added in order to broaden the scope of coverage.

  • Based on 2023-01-13, 15, 16 lab data, there is no evidence that the patient’s liver or kidney function has declined. Therefore, no dose adjustment is required for the medication prescribed.

2023-01-06

  • Cimetidine may increase the serum concentration of metformin. The AUC of metformin increased 40% when combined with a single dose of cimetidine (400 mg) and increased 50% after treatment with cimetidine (400 mg twice daily) for 5 days in healthy volunteers. In an another study of 15 healthy volunteers, cimetidine administration decreased metformin renal tubular clearance by 18.7% to 48.2%, depending on the individual’s organic cation transporter 2 (OCT2) genotype. Participants carrying the OCT2 808G>T polymorphism had lower baseline tubular clearance of metformin and a correspondingly lower magnitude of interaction with cimetidine.

  • As the patient’s renal function still works (2023-01-05 Cre 1.08mg/dL, eGFR 53, BUN 14mg/dL), it is less likely to develop lactic acidosis, however, close monitoring might be necessary.

  • The historical time series lab data suggest that the roughly cyclic trough WBC level (neutropenia events) was frequently observed around 3 weeks following each R-CHOP treatment. It might be necessary to plan in advance for the possible neutropenia 3 weeks after this hospital stay in order to ensure the G-CSF is accessible to the patient during the Chinese New Year long holidays.

2022-09-01

  • Diagnosed T2DM. Glucose One Touch data: 228 (2022-08-31 17:05), 203 (2022-09-01 06:09), 256 (2022-09-01 11:12). No HbA1c records found.

  • This patient is taking self-carried gliclazide 15mg QD and metformin 500mg TIDCC.

  • Suggestion:

    • check HbA1c
    • add Forxiga (dapagliflozin 10 mg) 1# QD (preferred) or Trajenta (linagliptin 5 mg) 1# QD to achieve a fasting glucose level below 200 mg/dL.
    • please monitor for UTIs while the patient taking dapagliflozin.

701351712

230116

  • diagnosis - 20230111 discharge note
    • Malignant neoplasm of lower third of esophagus
    • Malignant neoplasm of prostate
    • Squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA status post percutaneous endoscopic gastrostomy and port-A catheter implantation on 2022-09-05
    • Prostatic adenocarcinoma, cT3bN1M1 cstage IVB
    • Chronic viral hepatitis B without delta-agent
  • past history - 20230103 admission note
    • Prostate cancer status post hormone therapy since 2022/03/16
    • Smoking (2 packs per day) and Drinking alcohol (over 1 bottled of whistsky) for 40 years, quited 20 years ago
    • Parkinsonism under follow up at our neurology outpatient department
    • Peptic ulcer disease status post medication about 20 years ago
    • Cervical herniated intervertebral disc status post surgery 30 years ago 
  • exam findings
    • 2023-01-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 13.4) / 93 = 85.59%
        • M-mode (Teichholz) = 85
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Poor echo window
    • 2023-01-04 CT - chest
      • Indication: Malignant neoplasm of lower third of esophagus Malignant neoplasm of prostate, T3(T_value) N:N3
      • Findings
        • Lungs: extensive, bilateral upper lobes predominant, centrilobular emphysema, in the lungs. minimal fibrotic change at RLL and several small granulomas at RUL.
        • Mediastinum and hila: interval disappearance an intraluminal heterogeneous tumor at distal thoracic esophagus compared with CT on 2022/08/31
          • small LNs in upper paratracheal spaces and A-P window. old calcified LNs in the visceral space and anterior prevascular space, may be sequela of previous TB infection.
        • Vessels: extensive calcified plaques of the LAD, and LCX, and right coronary arteries.
        • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
        • Pleura: Rt apical fibrothorax. moderate-sized Lt effusion.
        • Chest wall and visible lower neck: no LAP
        • Visible abdominal contents: s/p percutaneous gastrostomy.
          • regions of atrophic change of Lt kidney. multiple metastatic LAP at E-G junction, along the celiac axis, significant in regression. mild dilated extrahepatic bule duct.
          • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and Rt kidneys.
        • Visualized bones: no destructive lytic or blastic lesion.
      • Impression:
        • D/3 esophageal cancer T3N3, significant in regression compared with CT 2022/08/31
    • 2022-11-30 Patho - esophageal biopsy
      • Labeled as “esophagus”, biopsy — ulcer.
      • IHC stain: CK highlights regular mucosa.
      • Section shows bland squamous mucosa with abundant ulcer debris.
    • 2022-11-30 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal scar, C/W Hx of esophageal cancer, L/3, s/p biopsy
        • Reflux esophagitis LA Classification grade A
        • Hiatal hernia
        • Superficial gastritis
        • PEG in situ
      • Suggestion
        • Pursue the result of pathology report
    • 2022-10-25 Bladder sonography
      • PVR 290 mL
    • 2022-10-11, -10-04 CXR
      • S/P port-A implantation.
      • Emphysematous change of both lung field
      • Borderline cardiomegaly
      • s/p percutaneous endoscopic gastrostomy
    • 2022-09-12, -09-08 CXR
      • areas of hyperlucency and decreased lung vascular markings due to emphysematous change of both lungs upper lung predominance
      • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
      • Coronary arterial calcification indicating CAD
      • Port-A catheter inserted into SVC via left subclavian vein.
      • small Lt pleural effusion?
    • 2022-09-07 ECG
      • Sinus tachycardia with Premature atrial complexes with Aberrant conduction
    • 2022-09-01 Whole body PET scan
      • Glucose hypermetabolism involving the lower portion of the esophagus, compatible with primary esophageal malignancy.
      • Glucose hypermetabolism in a subcarinal lymph node and possible some lymph nodes in the upper abdomen around the EG junction. Metastatic lymph nodes may show this picture.
      • Mild glucose hypermetabolism in bilateral pyriform sinuses. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulaiton may show this picture.
    • 2022-09-01 Bronchoscopy
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was moderately narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Oral and laryngeal mucosal candidiasis, diffuse.
    • 2022-09-01 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (21 - 7) / 21 = 66.67%
        • M-mode (Teichholz) = 65
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR and trivial TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
      • Dilated aortic root
      • A tumor size 3.97x3.2 cm external compress LA. It induce LA volume very smal, maybe low preload status.
    • 2022-08-31 Nasopharyngoscopy
      • Smooth oral cavity, oropharynx and nasopharynx
      • Much saliva and sputum cumulation at bil. piriform sinus and esophageal inlet, cannot see mucosal surface well
      • Post. pharyngeal wall protruding with smooth mucosal surface
    • 2022-08-31 Pulmonary Flow Volume Loop
      • Mild restrictive and mild to moderate obstructive pulmonary function impairment
    • 2022-08-31 CT - chest
      • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2022-08-26 Patho - esophageal biopsy
      • Ulcerative tumor, from 35 cm below the incisors to EC Junction, biopsy — Squamous cell carcinoma
      • The specimen submitted consisted of three small pieces of esophageal tumor tissue measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections in one cassette.
      • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the esophageal tumor tissue characterized by some solid tumor cell nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with keratin formation. Besides, ulceration, bacteria (bacilli) and fungal spores and hyphae, which morphology compatible with candidiasis are also noted.
      • Immunohistochemical stains of CK(+), P63(+), P16(-), PSA(-) and P53 (+, focal) for tumor.
    • 2022-08-25 Esophagogastroduodenoscopy, EGD
      • Esophageal tumor with luminal narrowing, 35cm below incisor to ECJ, s/p biopsy
      • Whitish esophageal mucosa, 20cm to 35cm below incisor, suspected food coating
      • Deformed antrum and GU scar, antrum
      • Superficial gastritis
      • DU scar, bulb
    • 2022-08-03 Sinoscopy
      • Dysphagia, may be parkinsonism related
    • 2022-05-11 Bladder Sonography
      • PVR 100.09 mL
    • 2022-05-11 Uroflowmetry
      • Q max: low
      • flow pattern: obstructive
    • 2022-05-04 MRA - brain
      • Old cerebral and left cerebellar infarcts. Intracranial artherosclerosis. General brain atrophy.
    • 2022-03-23 Electroencephalography, EEG
      • This EEG study recorded background alpha rhythm (8-9 Hz) and beta activity.
      • No epileptiform discharge.
      • Please correlate with clinical features.
    • 2022-03-11 MRI - prostate
      • Imaging Report Form for Prostate Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
    • 2022-02-22 Tc-99m MDP whole body bone scan
      • Mildly increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture.
      • Increased activity in the lower portion of bilateral S-I joints. The nature is to be determined (degenerative change? other nature?). Please correlate with other clinical findings for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2022-02-10 Patho - prostate needle biopsy
      • Prostate, left and right, biopsy — Prostatic adenocarcinoma, Gleason grade 4+4 — 6 out of 6 tissues involved, occupying 50% of tissues
      • Microscopically, section shows Gleason-grade 4+4 adenocarcinoma composed of proliferation of crowded, fused and irregular neoplastic glands and infiltrative growth pattern. The neoplastic acini are lined by a single layer of epithelial cells and absent of basal layer. The epithelial cells are cuboidal and shows pleomorphic nuclei and hyperchromasia.
      • Immunohistochemical stain reveal AMACR(+) and 34BE12(-).
    • 2022-02-08 CXR
      • Post-op at C-spine.
      • No cardiomegaly.
      • Fibrotic infiltrates in right lung apex.
      • Thoracolumbar spondylosis.
    • 2022-02-08 ECG
      • Sinus rhythm with occasional Premature ventricular complexes
    • 2022-01-04 Uroflowmetry
      • Q max: low
      • flow pattern: obstructive
    • 2022-01-04 Bladder Sonography
      • PVR 179 mL
    • 2021-12-14 Transrectal Ultrasound of Prostate, TRUS-P
      • Prostate
        • Size of prostate: 4.77(T)cm x 3.94(L)cm x 4.83(AP)cm = 47.2cc
        • Size of adenoma: 4.18(T)cm x 3.19(L)cm x 3.14(AP)cm = 21.8cc
      • Diagnosis: Benign prostatic hyperplasia
    • 2021-12-14 Uroflowmetry
      • Q max: low
      • flow pattern: obstructive
    • 2021-12-08 Bladder Sonography
      • PVR 381 mL
      • TPV 41
      • irregular posterior wall
  • consultation
    • 2022-09-07 Gastroenterology
      • Q
        • After admission, cancer work-up was completed. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA. We has well explaining with patient and his family about further treatment. Further CCRT will be performed. Owing to anti Hbc positive, we need consult you for Entecarvir treatment before chemotherapy. Thanks a lot !
      • A
        • S
          • A case of newly diagnosis with squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA
          • We are consulted of Entecarvir treatment before chemotherapy
          • Plan: schedule chemotherapy at next admission
        • O
          • HBsAg: Nonreactive (8/31)
          • Anti-HBc: Reactive (8/31)
          • Anti-HCV: Nonreactive (8/31)
          • Bilirubin total: 1.43 (8/31)
          • S-GOT/AST: 17 (8/30)
          • eGFR: 63.28 (8/30)
        • P
          • Baraclude 0.5mg (GFR >50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR<15 or HD QW)
          • HBV carrier (HbsAg(+) or HbsAg(-) but anti-Hbc ab(+))
          • Start the Baraclude treatment 1 week before chemotherapy until 6 months after the end of chemotherapy.
          • Due to patient scheduled chemotherapy at next admission, may arrange GI OPD for prescribe Entecarvir 1 week before starting chemotherapy
    • 2022-09-07 Radiatoin Oncology
      • Q
        • After admission, cancer work-up was completed. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA. We has well explaining with patient and his family about further treatment. Operation of port-A catheter implantation and PEG was done on 2022-09-05. Thus we need consult you for radiotherapy. Thanks a lot !
      • A
        • This 83-year-old male patient has Parkinsonism disease and prostate cancer T3bN1M1a, with pelvic LAPs, status post hormone therapy since 20220316. This time, he suffered from swallowing difficulty for 4 months. Biopsy was done on 2022/08/25 and showed squamous cell carcinoma. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA.
        • Due to he and his family refused surgery, CCRT is indicated. CT-simulation will be arranged on 20220908. Plan to deliver 45 Gy/ 25 fx to the whole esophagus and adjacent lymphatic drainage area (including bil. SCF). Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 20220912. Thank you very much.
    • 2022-09-05 Hemato-Oncology
      • A
        • Impression
          • Squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA
          • Parkinsonism disease and prostate cancer T3bN1M1a status post hormone therapy since 2022/3/16
        • Suggestion
          • Anti Hbc positive, consult GI doctor for entecarvir before chemotherapy
          • We will discuss with patient and family about further systemic treatment. Please consult RT for further evaluation.
    • 2022-09-01 Thoracic Surgery
      • Q
        • This is a 83-year-old man , newly diagnoised with esophageal cancer, T3N3M0, pending obstruction.
        • Apart from the melignancy, there’s no specific underlying diseases.
        • We’d like to consult to you, with your expertise, we will have a better idea of the futher treatment for the patient.
      • A
        • I have explained possible preoperative CCRT followed by esophagectomy and gastric tube reconstruction.
        • Due to the patient’s old age and emphysema, the patient’s family preferred conservative treatment. As a result, definitive CCRT is suggested.
        • I will arrange EUS to complete esophageal cancer staging. Also, I will perform port-A catheter implantation and PEG for further CCRT and enteral nutrition support.
        • I will take over this case. Thanks for your consultation.
    • 2022-08-31 ENT
      • Q
        • This is a 83 y/o male with past history of prostate cancer s/p ADT, peptic ulcer, Parkisonism, VC HIVD S/P. This time, he was admitted due to dysphagia for 4 month, which was further biopsied and proved to be squamous cell carcinoma. Staging survey is still ongoing and uncertain but will be done in the next few days. We need your expertise to evaluate the presence of head and neck cancer or not. Thank you.
      • A
        • Local finding via scope (PACS):
          • Smooth oral cavity, oropharynx and nasopharynx
          • Much saliva and sputum cumulation at bil. piriform sinus and esophageal inlet, cannot see mucosal surface well
          • Post. pharyngeal wall protruding with smooth mucosal surface –> C-spine HIVD?
        • No obvious abnormal lesion noted via this exam, but cannot see bil. piriform sinus and esophageal inlet mucosal surface well
        • For further confirmation may consider LMS tumor mapping with ETGA, if needed and without contraindication of general anesthesia (ETGA = endotracheal tube intubation general anesthesia)
  • SOAP
    • 2022-10-26 Hemato-Oncology
      • due to improved mood and body weight after increasing calorie and fluid, may consider C/T with biweekly HDFL 3 weesk later.
  • radiotherapy
    • 2022-09-13 ~ 2022-10-26 completed RT to the esophagus and adjacent lymphatic drainage area (including bil. SCF): 45 Gy/ 25 fx. The esophageal tumor: 48.6 Gy/ 27 fx.
  • chemotherapy
    • 2023-01-04 - leucovorin 300mg/m2 450mg 2hr + fluorouracil 300mg/m2 450mg 10min + fluorouracil 2400mg/m2 3600mg 46hr (HDFL for esophageal cancer)
      • dexamethasone 4mg
  • medication
    • Leuplin Depot (leuprolide) CLEUP03, CLEUP01
      • 2022-10-25 11.25mg Q3M SC OPD
      • 2022-08-03 11.25mg Q3M SC OPD
      • 2022-05-11 11.25mg Q3M SC OPD
      • 2022-04-13 3.75mg Q4W SC OPD
    • Androcur (cyproterone acetate 50mg/tab)
      • 2022-03-16 ~ 2022-03-23 1# BID OPD
    • Vemlidy (tenofovir alafenamide 25mg/tab)
      • 2023-01-11 ~ 2023-01-18 1# QDCC IPD
      • 2023-01-04 1# ST IPD

==========

2023-01-16

  • Compared to the image of 2022-08-31, the CT of 2023-01-04 showed significant regress of multiple metastatic LAP along the celiac axis. Considering that esophageal SCC was not treated with chemotherapy by the end of 2022, but prostate cancer has been treated with leuprolide for months, could there be a diminished likelihood that the LAP originates from the esophagus? <- this might not be the right question for the patient has completed radiotherapy during 2022-09-13 ~ 2022-10-26.
  • The CT of 2023-01-04 also revealed extensive calcified plaques in the LAD, LCX, and right coronary arteries. Cilostazol may be indicated. 2D transthoracic echocardiography 2023-01-05 revealed an LVEF of 85%, Cilostazol is not contraindicated.
  • The patient’s body weight decreased by 2 kg during the past week (2023-01-03 49.6kg, 2023-01-10 47.5kg), Nutritional assistance may be required on a more intensive basis
  • Gastrostomy tube feeding is possible for all oral medications listed on the active prescription.

2023-01-04

  • In accordance with ECOG PS 4, there has been no C/T for R/T. R/T has been completed as of 2022-10-26.
  • The patient’s body weight increased from 42.4 kg on 2022-08-30 to 51 kg on 2022-09-13. However, no additional weight gain has occurred since then, even a slight decrease to 49.3 kg on 2023-01-03.
  • Left ventricular end-systolic volume index = 7 / 1.45 = 4.8 mL/m2; LVEF 67% (2022-09-01). Cilostazol is not contraindicated.
  • Tube feeding is possible for all oral medications listed on the active prescription. The current medication does not pose any problems.

701355603

230116

{poorly differentiated squamous cell carcinoma of esophagu, cT3N2M0 stage III; poorly differentiated adenocarcinoma of stomach with liver metastases, cT3N0M1, stage IV}

  • exam finding
    • 2022-08-10 CT - chest
      • further decrease in size of several poorly enhanciing hepatic tumors up to 22mm as compared with previous CT on 2022/04/26
      • collapse of thoracic esophagus without obvious wall thickening or intraluminal enhancing nodule or mass based on CT exam.
    • 2022-07-19 ECG
      • Normal sinus rhythm
      • Leftward axis
      • Inferior infarct, age undetermined
      • Abnormal ECG
    • 2022-04-26 CT - lung/mediastinum/pleura
      • Findings
        • Lungs:
          • normal appearance of both lower lobes and RML.
          • mild centrilobular emphysema in both upper lobes.
          • Mediastinum and hila: no enlarged LN or mass.
          • a small intraluminal lesion at upper third of thoracic esophagus.
        • Vessels:
          • mild calcified plaques in left main coronary artery.
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace Lt-sided effusion.
        • Chest wall and neck: unremarkable.
        • Visible abdominal-pelvic contents:
          • decrease in size of several poorly enhanciing hepatic tumors up to 30 mm compared with previous CT exam.
          • no obvious abnormal enhancing wall thickening or ulceration of stomach based on axial CT images
          • several small Rt renal cysts up to 5 mm.
          • normal appearance of gallbladder. unremarkable of the spleen, adrenal glands, and pancreas. no enlarged lymph node.
          • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
        • Visualized bones: unremarkable.
      • Impression:
        • decrease in size of several poorly enhanciing hepatic tumors up to 30 mm as compared with previous CT on 2021/12/28
        • a small intraluminal tumor at upper third of thoracic esophagus and no visible sessile like intraluminal lesion at distal thoracic esophagus compared witH CT on 2021/12/28.
    • 2022-03-08 Spirometry and Bronchodilator Test
      • normal baseline without significant reversibility
      • FEV1/FVC = 79%, FVC = 156%, FEV1 = 151%
    • 2022-01-27 Patho - esophageal biopsy
      • Labeled as “35cm from incisor’, biopsy — poorly differentiated malignancy.
      • Section shows pieces of necrotic tissue, pieces of bland squamoius tissue, and neoplastic tissue with diffuse infiltrtion of nests of neoplastic basaloid cells with dysplastic polygonal shape neoplastic cells. The differential diagnoses include, but not limited to, poorly differentiated squamous cell carcinoma, poorly differentiated adenosquamous carcinoma, poorly differentiated adenocarcinoma, and neuroendocrine carcinoma.
      • IHC stains (S2022-1781):
        • CK (diffuse strong +) and CK5/6 (+): compatible with poorly differentiated squamous cell carcinoma.
        • CD56 (-), chromogranin (-), CK7 (-), CK20 (-), CDX-2 (-), Her2/neu: negative =0).
    • 2022-01-27 Patho - stomach biopsy
      • Stomach, labeled as “high body, GC”, biopsy — poorly differentiated malignancy.
      • Section shows pieces of necrotic tissue, pieces of bland gastric glands tissue with diffuse infiltrtion of nests of markedly crushed neoplastic round blue cells. The differential diagnoses include, but not limited to, poorly differentiated squamous cell carcinoma, poorly differentiated adenosquamous carcinoma, poorly differentiated adenocarcinoma, and neuroendocrine carcinoma.
      • IHC stains (S2022-1782):
        • CK (focal +) and CK5/6 (-): poorly differentiated carcinoma, NON-squamous cell.
        • CD56 (-), chromogranin (-): dis-favor neuroendocrine origin;
        • CK7 (-), CK20 (-), CDX-2 (-);
        • LCA (focal +), CD3 and CD20 no monoclonality: dis-favor lymphoma.
        • Her2/neu: negative =0).
    • 2022-01-27 Miniprobe Endoscopic Ultrasound
      • Diagnosis
        • Esophageal cancer, at least cT3N2, 35 to 40cm from incisor, s/p biopsy
        • Gastric cancer, at least cT3, high body, GC, s/p biopsy
      • Suggestion
        • F/U patho
    • 2022-01-24 Patho - liver biopsy needle/wede
      • Liver, CT-guided biopsy — Poorly differentiated carcinoma with extensive tumor necrosis
      • The sections show poorly differentiated carcinoma, composed of a few viable large pleomorphic neoplastic cells in fibrous stroma with extensive tumor necrosis.
      • IHC shows: CK(+), CK7(-), CK20(-), and p40(-). Neither squamous nor glandular differentiation can be identified in the sections examined.
    • 2022-01-24 EKG
      • Left axis deviation
      • Low voltage QRS
    • 2022-01-20 CXR
      • Atherosclerotic change of aortic arch
    • 2022-01-20 KUB
      • Fecal material store in the colon.
      • Spondylosis of the L-spine is noted.
      • Disk space narrowing of L3-4 and L4-5 is suspected.
  • consultation
    • 2022-02-21 Radiation Oncology
      • Q
        • This 62 year old male has HBV, squamous cell carcinoma of esophagus suspected liver metastases, cT3N0M1 stage IV and adenocarcinoma of stomach suspected liver metastases, cT2N0M1 stage IV under FOLFOX for treatment since 2022-02. We need your help for RT assessment.
      • A
        • The patient’s history was reviewed and patient was examined.
        • S:
          • For radiotherapy due to esophageal and gastric cancer with liver metastasis.
          • PI: The patient was a case of poorly differentiated squamous cell carcinoma of the esophagus, stage cT3N2M0; and poorly differentiated carcinoma of the stomach, stage cT3N0M1, with liver metastasis. He suffered from body weight loss.
          • Family history: (father: gastric cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
          • Personal Hx: DM(-); HTN(+); HBV(+)
          • Previous RT Hx: (-)
        • O:
          • ECOG: 0
          • PE: neck and bil SCF: neg; bilateral low limbs: no edema; no tenderness and knocking pain of the bone.
          • KUB (2022-01-20): Fecal material store in the colon. Spondylosis of the L-spine is noted. Disk space narrowing of L3-4 and L4-5 is suspected.
          • CXR (2022-01-20): Atherosclerotic change of aortic arch.
          • Pathology (S2022-01455, 2022-01-26): Liver, CT-guided biopsy — Poorly differentiated carcinoma with extensive tumor necrosis
          • Miniprobe endoscopic ultrasound for upper GI (2022-01-27): Esophageal cancer, at least cT3N2, 35 to 40cm from incisor, s/p biopsy; Gastric cancer, at least cT3, high body, GC, s/p biopsy
          • Pathology (S2022-01681, 2022-02-01): CK (diffuse strong +) and CK5/6 (+): compatible with poorly differentiated squamous cell carcinoma. CD56 (-), chromogranin (-), CK7 (-), CK20 (-), CDX-2 (-), Her2/neu: negative =0). DIAGNOSIS: Labeled as “35cm from incisor”, biopsy (B) — poorly differentiated malignancy.
          • Pathology (S2022-01682, 2022-02-01): CK (focal +) and CK5/6 (-): poorly differentiated carcinoma, NON-squamous cell. CD56 (-), chromogranin (-): dis-favor neuroendocrine origin; CK7 (-), CK20 (-), CDX-2 (-); LCA (focal +), CD3 and CD20 no monoclonality: dis-favor lymphoma. Her2/neu: negative =0). DIAGNOSIS: Stomach, labeled as “high body, GC”, biopsy (A) — poorly differentiated malignancy.
        • A:
          • Poorly differentiated squamous cell carcinoma of the esophagus, stage cT3N2M0.
          • Poorly differentiated carcinoma of the stomach, stage cT3N0M1, with liver metastasis.
        • P:
          • Radiotherapy is indicated for this patient with the following indicators: esophageal cancer, stage cT3N2M0.
          • Goal: palliation
          • Treatment target and volume: esophageal tumor, peripheral involved, and regional lymphatic area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 4500cGy/25 fractions of the esophageal tumor, peripheral involved, and regional lymphatic, and 5040cGy/28 fractions of the esophageal tumor bed area.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sister. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-2-24
    • 2022-01-24 Gastroenterology
      • Q
        • This 62 year old male has history of 1) hypertention for two years under medication control 2) HBV without followed
        • The initial presentations were dizziness and abdominal fullness since Dec 2021. Therefore, he came to Chung Shan Medical University for help. EGD on 2021/12/08 which showed 1) Reflux esophagitis, LA grade A 2) esophageal poyps 1cam at 35cm post lower esophagus suspected maligant polyp s/p tissue biopies. 3) Gastric ulcer, maligancy can not be rule out, GC side of upper body, s/p tissue biopies. EUS was performed on 2021/12/28 and biopsy of esophagus and stomach were sent. Pathology of esophgus proved squamous cell carcinoma and pathology of stomach proved adenocarcinoma. CT was performed on 2021/12/31 revealed 1) proven gastric and esophageal cancer 2) liver metastatic tumors. PET on 2022/01/11 showed cT3N0M1 disease for esophageal carcinoma and cT2N0M1 disease for gastric carcinoma. Owing to personal reason, he came to our ONC OPD for help.
        • Liver biopsy done on 2022/01/24 and pending, we need your expertise for further management.
      • A
        • Finding
          • 62M
          • EGD(2021/12/08):
              1. Reflux esophagitis,LA grade A
              1. Esophageal poyps 1cm at 35cm post lower esophagus suspected maligant polyp s/p tissue biopies.
              1. Gastric ulcer,maligancy can not be rule out, GC side of upper body, s/p tissue biopies
          • EUS(2021/12/28)
              1. Esophageal cancer, uT3N0
              1. Gastric cancer, EUS staging undefined (at least T2 according to the imaging pictures)
          • CT(2021/12/31)
              1. proven gastric and esophageal cancer
              1. Multiple liver metastatic tumors.
              • no signs of LC; arterial hypo-enhancement, favored mets
          • PET(2022/01/11)
              1. cT3N0M1 disease for esophageal carcinoma
              1. cT2N0M1 disease for gastric carcinoma
          • According to the previous report,
            • the endoscopy biopsy of the esophageal lesion: SCC, moderate differentiated
            • the endoscopy boipsy of the gastric lesion: poorly-differentiated adenocarcinoma in the specimen on 12/8, poorly-differentiated SCC in the specimen on 12/28
          • GI was consulted for further management
      • Impression:
        • Esophageal cancer, SCC
        • Gastric cancer, poorly-differentiated carcinoma; however, there was discrepancy between the two pathologic reports on 12/08 and 12/28 (SCC or adenocarcinoma)
        • Liver tumors, in favor of metastasis, s/p CT-guided biopsy
        • HBV carrier, without evidence of cirrhosis of liver
      • Suggestion:
        • Await biopsy result to determine the nature of liver tumor
        • Consider repeat EGD with EUS to re-staing and re-biopsy the gastric lesion
        • Check HbeAg, HBV DNA
        • Keep HBV prophylactic treatment
  • radiotherapy
    • 2022-03-07 ~ 2022-04-18 - 4500cGy/25 fractions (15 MV photon) of the esophageal tumor, peripheral involved, regional lymphatic, and 5040cGy/28 fractions of the esophageal tumor bed area.
  • chemotherapy
    • 2022-02-28 ~ undergoing - FOLFOX6

==========

2023-01-16

  • 2023-01-15 lab data
    • RBC 3.59 *10^6/uL
    • HGB 12.4 g/dL
    • MCV 104.2 fL
    • MCH 34.5 pg
    • MCHC 33.2 g/dL
  • MCV, MCH and MCHC
    • Anemia can be classified based on whether the MCV is low, normal, or elevated. A decreased MCV (usually less than 80 fL) indicates a defect in the synthesis of hemoglobin, which may be caused by an iron deficiency. And the presence of an increased MCV (>100 fL) is often attributed to asynchronous maturation of nuclear chromatin, although other factors may also contribute.

    • A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear, which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.

    • Very low MCHC values are typical of iron deficiency anemia, and very high MCHC values typically reflect spherocytosis or RBC agglutination.

  • The patient’s MCV and MCH were above normal limits, while his MCHC was within normal limits. There might be a lesser likelihood of an iron deficiency. Please confirm whether Foliromin (ferrous sodium citrate) is necessary.

2022-06-08

  • The survival outcomes of patients with synchronous primary esophageal squamous and gastric cancers were not worse than those of patients with isolated esophageal cancer or isolated gastric cancer. (Synchronous primary esophageal squamous cell carcinoma and gastric adenocarcinoma. https://www.nature.com/articles/srep13335 )
  • It was reported that cases of synchronous esophageal and gastric cancer were successfully treated by multimodal therapy or other methods. references:
  • The patient is able to tolerate the current FOLFOX6 regimen and lab data reported on 2022-06-07 were generally normal.

701458299

230116

  • diagnosis - 20230105 discharge note
    • Wild type, adenocarcinoma of Sigmoid with multiple liver metastases, T3N1M1a, stage IVA
    • Chronic viral hepatitis B without delta-agent
  • family history
    • Father: coronary artery disease
    • Monther: colon cancer
    • There is no family history of hypertension, mental diseases or asthma.
    • No members of the family with diabetes.
  • exam findings
    • 2022-11-04 CXR
      • Atherosclerotic change of aortic arch
    • 2022-10-28 CT - abdomen
      • CC: jaundice, tea-colored urine and poor appetite for 2 weeks
      • histroy of sigmoid colon cancer with liver metastasis S/P operation on 2022/06/17 at MacKay Memorial Hospital
      • Indication: sigmoid cancer with liver metastasis
      • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There are multiple heterogeneous poor enhancing masses on both hepatic lobes that are c/w metastases. The largest one is measured 12.8 cm in size (the largest dimension).
          • In addition, both lobe portal vein show small size that are c/w passive compression and encasement by the liver metastases.
          • The peripheral IHDs on both lobes show dilatation that is c/w tumor compression.
        • There is ascites, a soft tissue nodule at right upper pelvis omentum, and smudgy appearance of the middle omentum.
          • Carcinomatosis is highly suspected.
          • Please correlate with ascites cytology.
        • There is right UPJ stone 9 mm causing minimal hydronephrosis but no evidence of delayed contrast excretion.
        • S/P right hemicolectomy.
          • S/P LAR with autosuture retention over the rectum.
        • There is mild right side Pleura effusion.
        • There are few enlarged nodes in paratracheal space. Follow up is indicated.
          • In addition, There are few poor enhancing nodules on both lobe thyroid that may be nodular goiter.
          • Please correlate with sonography.
        • Others
          • There is no focal lesion in both lung.
          • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Multiple liver metastases on both lobes, causing total encasement of both lobe portal vein and dilatation of the peripheral IHDs.
        • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
    • 2022-10-27 SONO - abdomen
      • Diagnosis
        • Suspicious liver tumor with mucin production, both lobe
        • Hepatic cyst, right lobe
        • IHD dilation, left lobe
        • Ascites, mild
      • Suggestion
        • Please arrange other image to correlate clinical context
    • 2022-10-25 KUB
      • A calcified spot at RLQ.
    • 2022-10-25 CXR
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.
  • chemoimmunotherapy
    • 2023-01-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
    • 2023-01-03 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
    • 2022-12-19 - irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
    • 2022-12-06 - irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + palonosetron 250ug
    • 2022-11-21 - irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 3mg
    • 2022-11-07 - irinotecan 180mg/m2 190mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3200mg 46hr (TBI 6.09mg/dL, irinotecan x 0.75, 5-fu x 0.8)
      • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 3mg

[assessment]

  • As bilirubin total (0.67 mg/dL) and bilirubin direct (0.16 mg/dL) were both within normal ranges, no dose adjustment is required for irinotecan.

700169401

230113

  • exam findings
    • 2023-01-02 Patho - breast biopsy (no need margin)
      • Breast, right, core biopsy — invasive lobular carcinoma
      • Microscopically, it shows invasive lobular carcinoma composed of infiltrative neoplastic cells arranged in linear or single-file pattern in a sclerotic background. The tumor cells display uniform, small atypical cells with round nuclei and inconspicuous nucleoli and intracytoplasmic vacuolations.
    • 2022-12-31 CT - chest
      • Indication: Secondary malignant neoplasm of bone
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Diffuse lytic change at spine, long bones, bilateral ribs and pelvic bony structure is found. MM is compatible.
          • Minimal pleural effusion at bilateral basal lungs is found.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
          • Minimal soft tissue enhancement at right breast, r/o breast cancer.
          • Left breast enhanced nodule. Bilateral breast cancer is favored.
        • Visible abdomen:
          • Hypervascular heptic tumor at S6 of liver measuring 0.8cm in largest dimension is found. Hemangioma is favored.
          • The GB is well distended without soft tissue lesion
          • Soft tissue mass at myometrium measuring 4.1cm in largest dimension. Myoma is favored.
          • Right ovarian cyst measuring 3.05cm in largest dimension.
          • There is no ascites accumulation at abdominal cavity.
          • There is no evidence of destructive bone lesion.
          • Suggest clinical correlation
      • IMp:
        • Diffuse lytic change at bony structures. Bone meta is favored.
        • Suspected right breast cancer and left breast enhanced nodule. Bilateral breast cancer is favored. T2N0M1, Stage IV.
    • 2022-12-30 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, scapulae, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, bilateral humeri, femurs and possible the bone of right forearm.
      • IMPRESSION:
        • The scintigraphic findings suggest multiple bone metastases.
        • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture. Please correlate with other clinical findings.
    • 2022-12-29 Femur RT
      • There is osteolytic lesion in right femoral head, right intertrochanter, and bilateral pubic bone that may be bony metastases. Please correlate with CT.
    • 2022-12-29 CXR
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
      • Bony metastases are suspected.
    • 2022-12-29 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — metastatic carcinoma.
      • IHC stains: GATA-3 (+); E-cadherin (-): in favor of invasive lobular carcinoma of the breast. ER: (+, 95%, stron gintensity), PR (+, 95%, strong intensity), Her2/neu: Negative (score=0), Ki-67: 10%.
      • Section shows piece(s) of bone marrow with 50% cellularity and marked desmoplasia. There is a predominant round blue neoplastic cell population arranged in file or trabeculae pattewrn.
    • 2022-02-24 Gynecologic ultrasonography
      • ut: 91x28mm
      • Myoma: 36x22mm, 37x31mm, 27x24mm, 19x11mm, 30x23mm,
      • EM: 19.5mm
      • ROV: 27x15mm
      • LOV cyst: 19x18mm
      • IMP:
        • suspected Mild Adenomyosis
        • suspected Lt Ovarian cyst
        • Multiple myomas
  • medication
    • Zoladex (goserelin 3.6mg/syringe) CZOLA01 (10.8mg/syringe CZOLA02)
      • L02AE03. L02AE Gonadotropin releasing hormone analogues (See also H01CA - Gonadotropin releasing hormones). A combi-pack containing leuprorelin (L02AE02) injection and bicalutamide (L02BB03) tablets indicated for prostate cancer is classified in L02AE51.
      • 2023-02-02 3.6mg SC Q4W
      • 2023-01-05 3.6mg SC Q4W
    • Nolvadex (tamoxifen citreate 10mg/tab) KNOLV01
      • L02BA Anti-estrogens
      • 2023-01-05 ~ 2023-01-20 1# BID
    • Kisqali (ribociclib 200mg/tab)
      • L01EF02. L01EF Cyclin-dependent kinase (CDK) inhibitors. L01E PROTEIN KINASE INHIBITORS This group comprises protein kinase inhibitors used for neoplastic diseases. Substances are classified according to their main target. Substances which are multi-targeted without a clear main target are classified in L01EX. Lipid kinase inhibitors (phosphatidylinositol-3-kinase (Pi3K) inhibitors) are classified in L01EM.
        • The recommended dose of KISQALI is 600 mg (three 200 mg film-coated tablets) taken orally, once daily for 21 consecutive days followed by 7 days off treatment resulting in a complete cycle of 28 days. KISQALI can be taken with or without food.
      • 2023-01-05 ~ 2023-01-25 #3 QD

[assessment]

  • The patient was with her husband, who might be the primary caregiver, at the time of my visit approximately 08:45 on 2023-01-13. I gave the patient the Kisqali (ribociclib) empty package along with the insert inside.
  • It has been explained to the patient that they should be alert for any signs of adverse reactions of the drug such as interstitial lung disease, pneumonitis, cutaneous adverse reactions, prolonged QT intervals, hepatobiliary toxicity, and neutropenia; and to comply with the doctor’s instructions and cooperate with the regular lab tests.
  • A small amount of redness and itching can be seen on the back of the patient’s neck, and there appears to be a small break in the mouth near the lips. Please follow up.
  • There might be an increased QT prolongation with concomitant use of tamoxifen and ribociclib. KISQALI is not indicated for concomitant use with tamoxifen.
    • In MONALEESA-7, the observed mean QTcF increase from baseline was > 10 ms higher in the tamoxifen plus placebo subgroup compared with the non-steroidal aromatase inhibitors (NSAIs) plus placebo subgroup. In the placebo arm, an increase of > 60 ms from baseline occurred in 6/90 (7%) of patients receiving tamoxifen, and in no patients receiving an NSAI. An increase of > 60 ms from baseline in the QTcF interval was observed in 14/87 (16%) of patients in the KISQALI and tamoxifen combination and in 18/245 (7%) of patients receiving KISQALI plus an NSAI.
    • Data from a clinical trial in patients with breast cancer indicated that tamoxifen Cmax and AUC increased approximately 2-fold following coadministration of 600 mg ribociclib.
  • Following coadministration of ribociclib with anastrozole, letrozole, exemestane, and fulvastrant, clinical trial data indicate that there are no clinically relevant drug interactions between ribociclib and these drugs.
  • Palbociclib and abemaciclib are two other kinase inhibitors that are compatible with aromatase inhibitors and both are available in the stock.
  • Please monitor ECG and electrolytes very closely if the combination of ribociclib and tamoxifen cannot be avoided.

700126908

230112

[tube feeding]

Current administration routes are IVD and TPN; there is no tube feeding at this time.

700049597

230110

  • diagnosis - 2022-12-21 discharge note
    • Rectal cancer with stationary left lung metastases but increase in size of adrenal metastases stage IV
  • past history
    • Constipation for many years.
    • Left pleural effusion, left subphrenic and peri-splenic abscess s/p pig-tail drainage on 2008-03-17.
      • COPD, old TB with medications in our hopital regular follow.
    • History of operations: s/p left femoral fracture.
    • Regular medications:
      • Xanthium 200 mg QD
      • Anoro Ellipta INH.
  • exam finding
    • 2022-12-01 CT - abdomen
      • History and indication: Rectal cancer with stationary left lung metastases bur increase in size of adrenal metastases stage IV
      • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
      • With and without-contrast CT of abdomen-pelvis revealed:
        • Wall thickening of rectum.
        • Tumors (1.7cm, 3.7cm) at bil. adrenal regions.
        • Several nodules (up to 1.3cm) at left lung. Emphysema at bil. lungs.
        • Left renal cyst (0.5cm).
        • Atherosclerosis of aorta, iliac arteries.
        • S/P left femoral operation.
      • IMP: Rectal cancer with lung and adrenal metastases.
    • 2022-09-09 CT - abdomen
      • Findings:
        • Prior CT identified three metastases in LUL and LLL of the lung are noted again, decreasing in size (the maximal one 2.3 cm in prior CT and 1.6 cm at current CT) that are c/w lung metastases S/P C/T with partial response.
          • In addition, focal fibrotic change at RUL and emphysema of both lungs show stationary.
        • Prior CT identified metastases in right and left adrenal gland (4 cm and 2.2 cm) are noted again, stable in size that are c/w adrenal metastases S/P C/T with stable disease.
        • Prior CT identified several enlarged LNs at the mediastinum are noted again, decreasing in size that are c/w mediastinum LNs metastases S/P C/T with partial response.
        • Colostomy at right transverse colon is noted.
        • Left renal cyst (0.5cm).
      • Impression:
        • Lung metastases S/P C/T show partial response.
        • Bilateral adrenal metastases S/P C/T show stable disease.
        • Mediastinum LNs metastases S/P C/T show partial response.
    • 2022-06-29 CT - chest
      • rectal cancer with stationary left lung metastases but increase in size of adrenal metastases compared with CT on 20220224.
    • 2022-03-16 Patho - adrenal gland resection
      • Labeled as “right adrenal tumor”, core needle biopsy — metastatic adenocarcinoma.
      • IHC stains: CK 20 (+), CDX-2 (+), compatible with colonic origin.
      • Specimen submitted in formalin consists of 1 piece(s) of tissue measuring 2.4 x 0.3 x 0.3 cm. All for section(s) in one cassette(s).
    • 2022-03-07 Patho - lung transbronchial biopsy
      • Lung, LUL, CT-guide biopsy — consistent with metastatic colonic adenocarcinoma
      • Specimen submitted in formalin consists of 4 strips of tan, irregular tissue measuring up to 1.0 x 0.1 x 0.1 cm. All for section in one cassette.
      • Sections show acinar and cribriform glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal CDX2(+), TTF-1(-), and Napsin A(-). The results are consistent with metastatic colonic adenocarcinoma.
    • 2022-02-24 CT - abdomen, pelvis
      • Mild regression of recal cancer.
      • Progression of lung and adrenal tumors.
    • 2021-11-15 CT - abdomen, pelvis
      • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T3N2aM1a, stage IVA
    • 2021-11-12 Patho - colorectal polyp
      • Rectum, biopsy — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (weak +), MSH6 (+), MSH2(+), MLH1 (+).
      • Specimen submitted in formalin consists of 5 pieces of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm each. All for section in one cassette.
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • 2020-08-13 CT - lung/mediastinum/pleura
      • Imp: Severe COPD.
      • Bilateral apical lung fibrotic change.
    • 2019-06-04 Bronchodilator test
      • Flow-volum curve: Mild airway obstruction with significant response to bronchodilator.
    • 2018-09-18 Bronchodilator test
      • Flow-volum curve: Mild airway obstruction without significant response to bronchodilator.
    • 2017-10-17 Bronchodilator test
      • Flow-volum curve: Suspected small airway obstruction with significant response to bronchodilator.
    • 2017-01-24 Lung volume with function
      • Small airway obstruction with partial response to BD
      • Low IC, no HI, but air-trapping
      • Normal DLCO and normal raw favor smoking related small airway disease
  • consultation
    • 2021-11-15 Colorectal Surgery
      • This is a 66-year-old male with a known history of
          1. COPD for 10+year under medical control
          1. s/p left femoral fracture
      • This time, he experienced constipation for 2 days and dark brownish stool after colonscopy on 2021-11-11, which showed ulcerative mass above 10cm AV s/p multiple boipsy. Besides, lower abdominal pain was accompanied with constipation. So he came to our ER for help. At ER, vital signs were stable. And lab revealed normal liver and kidney function but elevated CRP without leukocytosis and stool OB 4+. CT showed colorectal cancer T3N2aM1a.
      • Lab
        • PE: RLQ tenderness, no rebounding pain, no muscle guarding, no bilateral knocking pain
        • Hb 16 -> 14.6
        • PT 10.7 INR 1.03
        • PLT 198000
      • Colorectal Carcinoma, T3N2aM1a
      • Constipation for 2 days
      • Dark brownish stool after colonscopy on 2021-11-11
      • Assessment
        • Rectal cancer, cT3N2aM1a (Left lung mets)
      • Plan
        • please arrange admission on CRS VS
        • supportive care
        • contact us if still have any CRS problems
  • surgical operation
    • 2021-11-17
      • Surgery
        • T-loop colostomy        
      • Finding
        • T-loop colostomy with stent was created at RUQ area   
  • radiotherapy
    • 2021-11-29 ~ 2022-01 - deliver 43.2 Gy/ 24 fx to the pelvis, then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx.
  • chemoimmunotherapy
    • 2023-01-09 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4230mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-12-19 - bevacizumab 5mg/kg 100mg 90min + oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 610mg 2hr + fluorouracil 2800mg/m2 4300mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-11-28 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4220mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-11-09 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4240mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-10-17 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 125mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4240mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-09-19 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2800mg/m2 4150mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-09-06 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2800mg/m2 4180mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-08-23 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-08-09 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-07-26 - bevacizumab 5mg/kg 200mg 90min + oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4200mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-07-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4250mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4250mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-06-02 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4270mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-05-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 270mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4290mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-04-28 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4300mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-04-15 - irinotecan 170mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4380mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-03-28 - irinotecan 170mg/m2 260mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 4400mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg IVD
    • 2022-01-05 - fluorouracil 225mg/m2 350mg 24hr (CCRT)
    • 2021-12-20 - fluorouracil 225mg/m2 350mg 24hr D1-5 (CCRT)
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2021-12-13 - fluorouracil 225mg/m2 350mg 24hr D1-5 (CCRT)
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2021-12-09 - fluorouracil 225mg/m2 350mg 24hr D1-2 (CCRT)
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

==========

2022-05-19

  • The patient was diagnosed with colorectal carcinoma T3N2aM1a stage IVA, had a T-loop colostomy performed in November 2021, received CCRT from December 2021 to January 2022, and then began receiving palliative FOLFIRI in March (plus bevacizumab in April).
  • The most recent CT (2022-02-24) revealed a mild regression in colon cancer and a progression of lung and adrenal tumors. In March 2022, biopsies subsequently confirmed that the lung and adrenal tumors were metastatic colonic adenocarcinomas.
  • According to lab data reported on 2022-05-18, there were generally normal results. His underlying COPD is followed up in our office of thoracic medicine with refillable prescriptions.

700510940

230110

{not completed}

  • exam findings
    • 2022-12-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (52 - 10) / 52 = 80.77%
        • M-mode (Teichholz) = 82
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Degenerative changes of mitral and tricuspid valves and marked posterior mitral annulus calcification with mild MR; trivial TR.
    • 2022-12-20 SONO - abdomen
      • A hepatic cyst 8 mm in S6 is noted.
      • A renal stone 0.51 cm in right kidney is suspected.
    • 2022-11-21 ECG
      • Normal sinus rhythm
      • Right atrial enlargement
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-09-27 Patho - breast mastectomy with regional lymph nodes
      • Diagnosis
        • Breast, right, simple mastectomy (S2022-16451) — Invasive carcinoma. No special type. NST.
        • Resection margin: free.
        • Lymph node, right, sentinel lymph node biopsy with frozen section (F2022-454FSB) — free (0/1)
        • Lymph node, right, Non-sentinel lymph node biopsy with frozen section (F2022-454FSA) — fibroadipose tissue; no lymph node, no malignancy.
        • pT1a pN0 (if cM0); anatomic stage: IA; pathology prognostic stage: IB
      • Gross Description
        • Procedure
          • right, simple mastectomy (S2022-16451): 12 x 8 x 3 cm with intact skin: 8 x 3 cm. Nipple present not retracted. Grossly tumor-like lesion: 1.8 x 1.2 x 0.4 cm, located at > 1 cm from all side margins. (Microscopiccaly, invasive component is 1.5 x 1 mm).
          • Lymph node sampling (if lymph nodes are present in the specimen)
          • sentinel lymph node biopsy with frozen section (F2022-454FSB)
          • Non-sentinel lymph node biopsy with frozen section (F2022-454FSA)
        • Specimen laterality- right
          • Sections are taken and labeled as:
            • Tissue for frozen section: F2022-454 FSA: SLN; FSB.
            • Tissue for formalin fixation: S2022-16451A1: four side margin: A2-4: tumor with deep margin (inked); A5: nipple.
      • Microscopic Description
        • For Invasive Carcinoma
          • Histologic type:
            • Invasive carcinoma, no special type, NST
          • Size of invasive carcinoma (mm): largest focus: 1.5 x 1 mm
          • Histologic grade (Nottingham histologic score): grade II (score 6,7)
          • Extent of tumor (required only if the structures are present and involved)
            • Skin involvement: Absent
            • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue submitted.
        • For Ductal Carcinoma In Situ-
          • Tumor size (mm): largest focus 10 x 2 mm
          • Nuclear grade: 2
          • Architectural pattern: Comedo
          • Tumor necrosis: Present
        • Margins:
          • Negative, Closest margin (4 mm from deep margin)
        • Nodal status: Negative
          • No. examined: 1
          • No. macrometastases (>2 mm): 0
          • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
          • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received) - no presurgical (neoadjuvant) therapy.
        • Immunohistochemical Study: result of biopsy specimen: S2022-15368: ER (-), PR (-), Her2/neu: negative (0/1+), Ki-67 inedex: < 10%.
    • 2022-09-20 PET
      • Mild glucose hypermetabolism in a focal area in the right breast, compatible with breast malignancy of low FDG uptake.
      • Glucose hypermetabolism in the nasopharynx. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammation may show this picture.
    • 2022-09-13 Patho - breast biopsy (no need margin)
      • Breast, right, core needle biopsy — Invasive carcinoma of no special type
      • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism,and increased N/C ratio.
      • Immunohistochemical study demonstrates ER (-), PR (-), Her2/neu: negative (0/1+), p53( complete -, aberrant-type), p63(-), Ki-67 inedex: < 10%.
  • chemoimmunotherapy
    • 2022-12-14 - fluorouracil 500mg/m2 570mg 30min + liposome doxorubicin 30mg/m2 34mg 2hr + cyclophosphamide 500mg/m2 570mg 1hr
      • diphenhydramine 30mg + betamethasone 8mg + famotidine 20mg + granisetron 1mg
    • 2022-11-22 - fluorouracil 500mg/m2 564mg 30min + liposome doxorubicin 30mg/m2 34mg 2hr + cyclophosphamide 500mg/m2 564mg 1hr
      • diphenhydramine 30mg + betamethasone 8mg + famotidine 20mg + granisetron 1mg

==========

2023-01-10

  • As of 2023-01-10, no neutropenia was detected in the lab result.
    • 2023-01-10 WBC 3.60 *10^3/uL
    • 2023-01-04 WBC 1.53 *10^3/uL

[duplicate note]

  • Please disregard this duplicate note generated by the system.

2023-01-05

  • Lab data on 2023-01-04 indicated that WBC was 1.53 K/uL. It was therefore decided to cancel the scheduled admission for FAC regimen treatment.

700736705

230110

  • diagnosis - 2023-01-10 discharge note
    • Squamous cell carcinoma of left mandibular gingiva, cT4aN2bM0, stage IVA
    • Infection of the left mandibular gingiva and bone
    • Agranulocytosis secondary to cancer chemotherapy
    • Encounter for antineoplastic chemotherapy
    • Essential (primary) hypertension
  • exam findings
    • 2022-11-23 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed one hot spot in the left aspecr of mandible, faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, elbows, right S-I joint, hips, and knees, in whole body survey.
      • IMPRESSION:
        • One hot spot in the left aspecr of mandible, the natur eis to be determined (advanced cancer or other nature ?), suggesting PET scan for further investigation.
        • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, elbows, right S-I joint, hips, and knees.
    • 2022-11-22 MRI - nasopharynx
      • Indication: Squamous cell carcinoma of left mandibular gingiva, cT2N2bM0, stage IVA. For tumor survery
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
        • Thin left anterior low gingiva tumor mass, extending to anterior mouth floor, and highly suspect of genioglossus muscle invasion, up to 15 mm measured on the coronal images.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • Multiple enlarged left level I-II LNs.
      • IMP:
        • Left low gingiva-mouth floor CA, T4AN2BM0 stage IVA.
      • Imaging Report Form for Oral Cavity Carcinoma
        • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
    • 2022-11-22 SONO - abdomen
      • Tiny gallbladder polyp
    • 2022-11-09 Patho - gingival/oral mucosa biopsy
      • Lingual gingiva (from #31 to #34) , left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Rare keratin formation is present. Mucosal ulcer and tumor necrosis can be found also.
    • 2022-11-08, -08-16, -07-26 KUB
      • Lumbar spondylosis.
    • 2022-08-02 SONO - kidney
      • Right renal stone
    • 2022-08-02 SONO - kidney
      • Right hydronephrosis
  • chemotherapy
    • 2023-01-06 - docetaxel 36mg/m2 60mg 1hr + cisplatin 36mg/m2 60mg 2hr + [leucovirin 90mg/m2 150mg + fluorouracil 900mg/m2 1500mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-12-27 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-12-13 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-12-06 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • medication
    • UFT (tegafur 100mg + uracil 224mg) KUFT01
      • 2022-11-29 ~ 2022-12-03 2# BID 20221129 OPD
      • 2022-11-25 ~ 2022-11-29 2# TID 20221121 IPD
    • Zinga (zinc gluconate 78mg/tab) KZING
  • zinc supplement related ref:
    • Hoppe C, Kutschan S, Dörfler J, Büntzel J, Büntzel J, Huebner J. Zinc as a complementary treatment for cancer patients: a systematic review. Clin Exp Med. 2021;21(2):297-313. doi:10.1007/s10238-020-00677-6
    • Abt E. Zinc Supplementation May Reduce the Effects of Oral Mucositis for Patients With Cancer Receiving Either Chemotherapy or Radiotherapy. J Evid Based Dent Pract. 2020;20(4):101494. doi:10.1016/j.jebdp.2020.101494
    • Chaitanya NC, Shugufta K, Suvarna C, et al. A Meta-Analysis on the Efficacy of Zinc in Oral Mucositis during Cancer Chemo and/or Radiotherapy-An Evidence-Based Approach. J Nutr Sci Vitaminol (Tokyo). 2019;65(2):184-191. doi:10.3177/jnsv.65.184

[assessment]

  • As of 2023-01-10, WBC is 2.87K/uL, neutrophil is 53%, and ANC is greater than 1500 cells/uL.

  • However, there is a trend downward in WBC count which should be noted.

    • 2023-01-10 WBC 2.87 *10^3/uL
    • 2023-01-06 WBC 7.22 *10^3/uL
    • 2023-01-03 WBC 3.43 *10^3/uL
    • 2022-12-31 WBC 5.11 *10^3/uL
    • 2022-12-27 WBC 5.52 *10^3/uL
    • 2022-12-17 WBC 3.83 *10^3/uL
    • 2022-12-13 WBC 4.57 *10^3/uL
    • 2022-12-10 WBC 8.21 *10^3/uL
    • 2022-12-04 WBC 7.02 *10^3/uL
    • 2022-11-21 WBC 6.61 *10^3/uL
    • 2022-08-02 WBC 5.71 *10^3/uL

700842151

230110

  • diagnosis - 20230109 admission note
    • Adenocarcinoma of rectosigmoid junction colon, cT3N2M0, stage: IIIB with with intussusception and partial obstruction status post Laparoscopic low anterior resection(LAR) on 2021/12/02
    • Chronic viral hepatitis B without delta-agent anti-Hbc: positive
  • past history
    • C3-6 spondylosis with spinal stenosis s/p laminoplasty on 2006-12-21.
    • Squamous cell carcinoma of upper third esophageal, T3N2M0, stage IIIB since Oct 2014, post Port-A on 2014-10-23, complete CCRT until Feb 2015. Post VATS esophagectomy with RLND, laparoscopic gastric tube reconstruction and feeding jejunostomy on 2015-03-09, ypT3N0M0, Stage IIB.
    • Esophageal stenosis s/p ballon dilation on 2015-05-21 and bilateral pleural effusion, chyothorax post close drainage on 2015-05-21.  
  • family history
    • There is no family history of diabetes, hypertension, mental diseases or asthma.
    • No members of the family with cancer.
  • exam finding
    • 2022-12-22 MRI - brain
      • Clinical information: Adenocarcinoma of rectosigmoid junction colon, cT3N2M0, stage: IIIB with with intussusception and partial obstruction status post Laparoscopic low anterior resection (LAR) on 2021/12/02
      • Findings:
        • Mild periventricular small vessel disease. NO acute ischemic infarct.
        • One old lacuna infarct over right internal capsule.
        • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
        • Left mastoiditis.
      • Impression:
        • No evidence of brain metastasis.
    • 2022-12-13 Chest PA + Lat LT
      • Few linear and nodular opacities projecting at bilateral middle lung zone are noted. please correlate with clinical condition and CT.
      • Atherosclerotic change of aortic arch
    • 2022-12-08 Peripheral Vascular Test - Vein, lower limbs
      • Conclusion:
        • Both arm MVO/SVC is normal
        • Left jugular vein is small and patency
        • There is no thrombus was seen in both upper arm
      • Suggestion
        • dupplex of vein could not scan proximal subclavian vein and central vein lesion, if consider central vein lesion, IVDSA or CT with contrast is indication.
    • 2022-12-07 CT - abdomen
      • History:
        • 20211111 CT: Adenocarcinoma of RS junction colon, cT3N2M0, stage: IIIB with intussusception and partial obstruction
        • 20211203 S/P LAR:pT3N2a(if cM0); stage IIIB
        • Past Hx: Eso. ca. s/p op,
      • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • S/P LAR with autosuture retention over the rectosigmoid junction.
        • S/P esophagectomy with gastric tube reconstruction via retrosternal space.
        • There are several hepatic cysts in both lobes and the largest one 1.4 cm in size at S5.
        • Prior CT identified several enlarged nodes in paratracheal space, right hilum, and subcarina space are noted again, mild decreasing in size that may be Metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
          • In addition, patchy areas of consolidations and ground-glass opacities in perihilar lungs, with tree-in-bud and centrilobular nodules in peripheral of RUL as well as subsegmental ground-glass opacity in superior segment of LLL, stationary.
        • Others
          • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P LAR with autosuture retention over the rectosigmoid junction. There is no evidence of tumor recurrence.
        • Prior CT identified several enlarged nodes in paratracheal space, right hilum, and subcarina space are noted again, mild decreasing in size that may be Metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
    • 2022-12-06, -11-13 KUB
      • Spondylosis of the L-spine is noted.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4, L4-5 and L5-S1.
      • S/P metalic autosuture at the rectum.
    • 2022-12-06, -11-28, -11-25, -11-24 CXR
      • Atherosclerotic change of aortic arch
      • Nodular opacity projecting in the bilateral middle lung are suspected. Please correlate with CT.
    • 2022-10-26, -10-12 CXR
      • Atherosclerotic change of aortic arch
    • 2022-09-08 CT - abdomen
      • S/P colon operation.
      • S/P gastric tube reconstruction.
      • Liver cysts (up to 1.2cm). A hypodense nodule (0.4cm) at left hepatic lobe.
      • Some tiny nodules in bil. lungs (mild regression).
    • 2022-05-04 Patho - lung transbronchial biopsy
      • Lung, left, CT-guide biopsy —- chronic inflammation with interstitial fibrosis
      • Sections show alveolar tissue with active interstitial fibrosis and chronic inflammation. Foamy cell aggregates and alveolar cell hyperplasia is also present. No definite granuloma, or malignancy is found.
      • The immunohistochemical stains reveal CK(+), TTF-1(+), and CDX2(-). Please correlate with the clinical presentation.
    • 2022-05-04 CT Guide biopsy
      • LLL lung nodule, s/p CT-guided biopsy
      • Due to tree-in-bud appearance in CT scans, an infectious process (tuberculosis?) shoulde be ruled out.
      • Suggest clinical correlation
    • 2022-04-29 Whole body PET scan
      • Glucose hypermetabolism in the right middle lung, highly suspected cancer with lung mets, suggesting biopsy for investigation.
      • Glucose hypermetabolism in the left upper, left lower, and right upper lungs, the nature is to be determined (inflammation/infecion process, lung mets or others ?), suggesting further investigation and close follow-up.
      • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, right mediastinal lymph nodes, right cervical lymph nodes and right infraclavicular lymph nodes, the nature is to be determined also (reactive nodes, metastatic lymph nodes or others ?), suggesting further investigation.
      • Esophageal and colon cancers with right middle lung metastasis at least, by this F-18 FDG PET scan.
    • 2022-04-10 KUB
      • Degeneration of bony structures.
      • Stool retention in bowl.
    • 2022-04-08 CT - abdomen, pelvis
      • S/P LAR with autosuture retention over the rectosigmoid junction. There is no evidence of tumor recurrence.
      • There are several enlarged nodes in the paratracheal space, right hilum, and subcarina space. Metastatic nodes are suspected.
    • 2021-12-03 Patho - colon segmental resection for tumor
      • pathologic diagnosis
        • Large intestine, colon, rectosigmoid junction, laparoscopic LAR — Adenocarcinoma, moderately differentiated
        • Resection margins, proximal and distal: free
        • Lymph node, mesocolic, dissection— Positive for adenocarcinoma (4/20)
        • Pathology stage: pT3N2a(if cM0); AJCC stage IIIB
      • microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: moderately differentiated
        • Depth of invasion: pericolorectal tissue
        • Angiolymphatic invasion: Present.
        • Perineural invasion: Not identified.
        • Discontinuous extramural tumor extension: Not identified
        • Circumferential (radial) margin of rectum: Uninvolved
        • Lymph node metastasis, mesocolic: Positive (4/ 20)
    • 2021-12-01 Sigmoidoscopy
      • advanced colorectal cancer, RS junction (25-28cm from AAV), s/p Tattoo injection
      • mixed hemorrhoid.
    • 2021-11-13 CT - chest
      • s/p esophagectomy with gastric tube reoncstruction.
      • Bilateral lung focal opacity, stationary. Previous inflammation is considered.
      • Intusussception of the sigmoid colon into rectum is found. Compatible with rectal cancer.
    • 2021-11-11 CT - abdomen, pelvis
      • Imaging stage: T3N2M0, stage IIIB
    • 2021-11-11 Patho - colon biopsy
      • RS junction, 25 cm to 28 cm AAV, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show a picture of adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
      • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2021-11-09 Sigmoidoscopy
      • Advanced colorectal cancer, RS junction(25cm to 28cm AAV), s/p biopsy
      • Mixed hemorrhoid.
    • 2021-06-08 CT - chest
      • No recurrent esophageal tumor. post treatment related change and inflammatory process RUL and LLL, stationary.
    • 2020-12-22 CT - chest
      • No recurrent esophageal tumor. post treatment related change and inflammatory process (infectious bronchiolitis) RUL and LLL (new lesion).
    • 2020-05-12 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process (infectious bronchiolitis) in lungs, stationary.
      • 2-vessels CAD.
    • 2019-11-03 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process (infectious bronchiolitis) in both lungs, slightly in progression.
      • 2-vessels CAD.
    • 2019-06-11 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, slightly in regression.
      • 2-vessels CAD.
    • 2018-11-29 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, stationary.
    • 2018-06-05 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, stationary.
    • 2017-12-13 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, in regression.
      • pneumonia in LLL?
    • 2017-06-14 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs.
      • pneumonia in LLL?
  • consultation
    • 2023-01-10 Radiation Oncology
      • Q
        • for R/O port-A obstruction
        • This 70-year-old man, a patient of colon cancer with lung mets S/P C/T. Owing to left port-A obstruction was noted. We need expertise to evaluate his condition thanks!
      • A
        • According to the clinical history and imaging findings, venography is indicated.
    • 2022-05-04 Radiation Oncology
      • A
        • This 69-year-old patient is a case of bilateral lung nodules, suspected pulmonary metastasis. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • surgical operation
    • 2021-12-02 Laparoscopic LAR        
      • A large locally advanced tumor at RS-colon with intussusception and partial obstruction. Some turbid (30ml) ascites was found at pelvic floor. Marked edema of the colon wall and dilatation with much soft0liquid stool retention.    
      • The whole procedure was smooth. Blood loss was less than 30ml.    
      • Adhesion of two segment of small bowel with anterior abdomen wall was seen.    
      • Anastomosis was achieved using endo-GIA/black*2 + CDH-33 + TISSEEL. Air test is ok.    
      • A drain in pelvis near anastomosis.    
    • 2018-03-21
      • Diagnosis
        • Paralysis of vocal cords or larynx, unilateral , complete
      • PCS code
        • 66008A
      • Finding
        • Complete paralysis of left vocal cord.
        • Sculptured silicon mass was inserted to left paraglottic space for adduct left vocal cord
  • chemoimmunotherapy
    • 2023-01-10 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/m2 4850mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-12-19 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/m2 4850mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-11-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-10-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-09-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-09-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-08-18 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 320mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-07-27 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-07-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-06-24 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-06-09 - irinotecan 170mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-05-24 - irinotecan 160mg/m2 290mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-04-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4980mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-04-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4980mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-03-23 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-03-08 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-02-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-02-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-01-17 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-01-03 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr

==========

2023-01-10

  • Vital signs are stable without extreme abnormalities in the 2023-01-09 lab results.
  • The suspected obstruction of the port-A is referred to Radiation Oncology for venography.
  • The patient has less yellowish sputum with his cough.

2022-12-20

  • The WBC level was elevated at 14K/uL on 2022-12-19, sputum was coughed up recently, and the scheduled chemotherapy was postponed due to a broncopnemonia event in late October 2022. Ciprofloxacin has been prescribed and the sputum culture is currently being conducted.

2022-12-07

  • The vital signs are stable. Lab data on 2022-12-06 showed no extreme abnormalities. A reduction in body weight of 5kg in the past six months (65.4kg 2022-12-07 <- 70.8kg 2022-06-08) might be caused by a lack of appetite.
  • The underlying condition of carrying HBV is appropriately managed with Vemlidy (tenofovir).

2022-04-25

  • The patient’s stage IIIB R-S colon cancer was treated with FOLFOX since 2022-01-03 following laparoscopic LAR on 2021-12-02.
  • On the CT images obtained on 2022-04-08, there were enlarged nodes in paratracheal space, right hilum, and subcarina space, which are suspected to be metastatic.
  • Lab results on 2022-04-22 showed liver and kidney functions, serum electrolytes, and blood cell counts were generally normal. However, the CRP level of 3.99 mg/dL and body temperature of 38.9 degrees were observed on 2022-04-23, which is currently being treated with tapimycin (piperacillin, tazobactam) 4.5gm IVD Q6H.

700954740

230110

{Recurrent left breast cancer with bilateral lung, right pleura, liver, bone and lymph node metastases, rcTxN2M1, stage IV}

  • lab data
    • CEA
      • 2022-08-02 CEA 24.80 ng/mL
      • 2022-07-12 CEA 35.48 ng/mL
      • 2022-04-19 CEA 224.79 ng/mL
    • CA153
      • 2022-08-02 CA153 643.7 U/mL
      • 2022-07-12 CA153 888.4 U/mL
      • 2022-06-23 CA153 1277.8 U/mL
      • 2022-04-19 CA153 4941.4 U/mL
    • CA199
      • 2022-06-23 4351.42 U/mL
    • Zinc, Zn
      • 2022-06-06 494 ug/L
      • 2021-11-15 432 ug/L
  • exam finding
    • 2023-01-09 SONO - chest
      • Bilateral pleural effusion (Left: moderate and Right: loculated minimal), post left pig-tail insertion.
    • 2023-01-08 CXR
      • Mass like lesion over RLL.
      • Bilateral pleural effusion.
      • Segmental atelectasis of both lower lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2023-01-03 SONO - chest
      • Right thorax: small amount pleural effusion.
      • Left thorax: moderate amount, serosanguinous pleural effusion s/p drainage of 550 cc pleural effusion.
    • 2022-12-27 SONO - chest
      • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
    • 2022-12-20 CXR
      • Rt greater than Lt bilateral pleural effusions and Rt lateral loculated effusion still visible
      • Osteoblastic metastasis in spine, Rt humeral head, and ribs
    • 2022-12-20, -12-06, -11-12, -10-25 CXR
      • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
      • Pleura effusion of bilateral costal-phrenic angle
      • S/P Mastectomy, left.
      • Osteosclerotic change at right humeral head is suspected.
    • 2022-12-20 SONO - chest
      • Left thorax: minimal amount pleural effusion
      • Right thorax: small amount pleural effusion s/p drainage of 250 cc, yellowish pleural effusion.
    • 2022-12-15 SONO - chest
      • pleural effusion
      • Chest echography was performed first. The suitable intercostal space was selected and located.
      • Catheter was inserted with negative pressure smoothly.
      • Left side pleural effusion was drawn smoothly.
    • 2022-12-15 SONO - abdomen
      • Diagnosis: Liver metastasis
      • Suggestion: Regular ultrasound follow up
    • 2022-12-06 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 210 ml yellowish
        • Pleural tapping 16 #-needle Left side 440 ml straw-color
    • 2022-10-06 KUB
      • Osteoblastic change of L3 vertebral body and bilateral ilium are noted that are c/w bony metastases.
      • Hepatomegaly is suspected.
    • 2022-10-06 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 390 ml serosanguineous
        • Pleural tapping 16 #-needle Left side 320 ml bloody
    • 2022-10-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (78.1 - 18.7) / 78.1 = 76.06%
        • M-mode (Teichholz) = 76
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Mild MR, TR and PR
      • No regional wall motion abnormalities
      • Sinus tachycardia during echocardiography
    • 2022-09-28 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 350 ml bloody
    • 2022-09-13 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 150 ml serosanguineous
        • Pleural tapping 16 #-needle Left side 270 ml bloody
    • 2022-08-23, -08-09, -07-22, -07-12 CXR
      • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
      • S/P port-A implantation.
      • Pleura effusion of bilateral costal-phrenic angle
      • S/P Mastectomy, left.
      • Borderline cardiomegaly
      • Osteosclerotic change at right humeral head is suspected.
    • 2022-08-11 CT - chest
      • Findings
        • Chest:
          • Bilateral loculated effusion more on right hemithorax is found.
          • S/p port-A placement with its tip at Superior vena cava.
          • S/P mastectomy at left side.
        • Visible abdomen:
          • Patch like low density area is found at both lobes of liver. Liver meta is considered. In comparison with CT dated on 2022-03-08, the lesions regressed.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no ascites accumulation at abdominal cavity.
      • Imp
        • S/P mastectomy at left side
        • Liver meta. In regression.
        • Bilateral pleural effusion, suspected pleural meta.
        • Bone meta, please correlate with bone scan study.
    • 2022-08-05 Bladder Sonography
      • PVR 45.6 mL (postvoided residual)
    • 2022-08-05 Uroflowmetry, UFR
      • flow pattern: obstructive
    • 2022-07-29 Bladder Sonography
      • PVR 8.47 mL (postvoided residual)
    • 2022-06-29 SONO - chest
      • symptom: dyspnea
      • indication: suspected pleural effusion
      • clinical diagnosis: left breast cancer post MRM in 2008, with liver, bone and bilateral malignant pleural effusion
      • procedure: The patient was in sitting upright posture while the chest echography was performed using 3.75-mHz convex probe.
      • findings:
        • There was no pleural effusion and it was free and anaechoic. Limited LLL and left hemidiaphragm movement was found.
        • No active lung lesion of left lung field
          • Left-side of thorax
          • Right-side of thorax
            • There was minimal pleural effusion
            • RLL atelectasis
      • echo diagnosis:
          1. Pleural effusion, minimal, right
          1. Consolidation, RLL
    • 2022-06-23 CXR
      • S/P port-A implantation.
      • Pleura effusion of right costal-phrenic angle
      • S/P Mastectomy, left.
      • Borderline cardiomegaly
      • Osteosclerotic change at right humeral head is suspected.
    • 2022-05-31 CXR
      • S/P port-A implantation.
      • Pleura effusion of right and left costal-phrenic angle
      • S/P Mastectomy, left.
    • 2022-05-16 Chest PA erect view
      • regression of massive moderate Rt pleural effusion s/p pigtail drain placement
      • resolution of Lt pleural effusion s/p pigtail drain placement
      • port-A catheter inserted into SVC via Right internal jugular vein
      • osteolytic/osteoblastic metastasis in spine,
      • normal heart size
    • 2022-05-13 Chest Ultrasound
      • Echo diagnosis:
        • Right side massive pleural effusion with lung passive collpase, s/p 14Fr. pig-tail catheter insertion smoothly
        • Left side small to moderate amount pleural effusion, s/p 14Fr. pig-tail catheter insertion smoothly.
    • 2022-04-26 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2021/12/07, some of the previous bone lesions are slightly more evident, suggesting multiple bone metastases in slight progression.
    • 2022-04-25 Cell block
      • Adenocarcinoma, in favor of breast origin
      • Smears and cell block show clusters and single cells of adenocarcinomatous cells with large hyperchromatic nuclei, pleomorphism and high N/C ratio.
      • Immunohistochemical stain reveals Calretinin(-), TTF-1(-) and GATA3(+).
    • 2022-04-25 Chest Ultrasound
      • Echo diagnosis:
        • Bilateral pleural effusion (Left: trivial and Right: moderate), s/p right diagnostic and therapeutic thoracentesis.
    • 2022-04-24 EKG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
    • 2022-04-08 Cell block
      • Positive for malignancy
      • 50 cc orange turbid right pleural effusion
      • The smears and cell block show many individual or clustering of hyperchromatic atypical epithelial cells, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
    • 2022-03-08 Her-2/neu DNA in Situ Hybridization, DISH
      • Result of Her2 in Situ Hybridization
        • HER-2 (by in situ hybridization) — Negative (NOT amplified)
      • Method and Details
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 signals per cell: 2.05
        • Average number of CEP17 signals per cell: 1.9
        • HER2/CEP17 ratio: 1.08
        • Heterogeneous signals: Absent
        • Origin slide and block number: S2022-3847
        • Specimen: Formalin-fixed paraffin embedded tissue
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • 2022-03-08 Patho - soft tissue/mass/lipoma/debridement
      • Diagnosis
        • Skin, left neck, excision — Consistent with metastatic breast carcinoma — Seborrheic keratosis
      • Microscopic description
        • Section shows one piece of hyperkeratosis, papillomatous skin with keratin cysts and interdigitation of epidermis and papillary dermis. A dermal tumor, measuring 0.5 x 0.4 x 0.3 cm, composed of pleomorphic tumor cells is seen. The immunohistochemical stain reveals GATA3(+). The morphology and immunohistochemical stain are consistent with metastatic breast carcinoma. The tumor is 0.1 cm away from the unspecified closest resection margin.
      • Immunohistochemical Study
        • ER (Ab): Positive (95%, strong)
        • PR (Ab): Negative
        • Her-2/neu (Ab): Equivocal (2+)
        • Ki-67: 30%
    • 2022-03-08 CT - liver, spleen, biliary duct, pancreas
      • S/P left breast operation. Progression of liver metastases. Stable condition of bony metastases.
      • Bil. pleural effusion.
    • 2021-12-07 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2020/09/22, more new bone lesions are noted, suggesting multiple bone metastases in progression.
    • 2021-12-06 SONO - breast
      • S/P left mastectomy.
      • Right breast cysts and fibroadenomas.
      • Left chest wall nodule, suggest follow up.
      • BI-RADS2. benign finding
    • 2021-12-06 CT - liver, spleen, biliary duct, pancreas
      • S/P left breast operation. Progression of liver and bony metastases.
    • 2021-05-19 SONO - breast
      • Status post left mastectomy.
      • Tiny right breast fibroadenomas.
      • Suggest follow up.
      • BI-RADS category 2, Benign finding.
    • 2021-05-10 Gynecologic ultrasonography
      • EM 5.0mm
    • 2021-05-04 CT - abdomen, pelvis
      • S/P left mastectomy. Multiple liver metastasis, progression.
      • Multiple bone metastasis.
      • Right axillary lymph node, metastasis?
    • 2021-04-22 SONO - abdomen
      • Bil. liver metastases (up to 2.1cm).
    • 2021-02-24 SONO
      • Metastases on both hepatic lobes are suspected and the largest one 3.35 cm in S7. Please correlate with contrast enhanced dynamic CT.
      • A hepatic cyst 0.7 cm in S3 is noted.
    • 2021-02-24 CT - lung/mediastinum/pleura
      • Findings
        • Lungs: nondependent subpleural fibrotic change in LUL, related to treatment. several nodular opacities in medial basal segment of RLL and a tiny nodule in S6 of the same lobe. nodularity of interlobar fissures in Rt lung.
        • Mediastinum: no enlarged LN or mass.
        • Hila: no enlarged LN or mass.
        • Vessels: aorta: normal appearance, central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace pleural effusion.
        • Chest wall: s/p Lt MRM< no LAP
        • Visible abdominal contents:
          • multiple metastatic hepatic tumors up to 3.2 cm (longest axial diamter).
          • normal appearance of gallbladder. gall bladder stones.
          • no abnormal density and size of visible portion of the unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. bile ducts: No dilatation.
          • no enlarged lymph node.
        • Extensive Mild atherosclerotic change of the abdominal aorta and bilateral common/external iliac arteries.
        • Visualized bones: lytic and blastic metastatic change in multiple vertebral bodies and left iliac wing..
      • Impression:
        • Lt brest ca s/p MRM with liver, bones, and lung metastases.
    • 2020-11-03 MRI - brain
      • No brain nodule or metastasis.
    • 2020-10-26 Patho - lymphnode biopsy
      • Lymph node, left neck, SONO guided core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (+, 95%, strong intensity), PR( +, 2-5%, intermediate intensity), Her2/neu: negative (score=1+), Ki-67(17%0), p53 (10%, weak intensity).
    • 2020-09-29 Whole body PET scan
      • Glucose hypermetabolism involving the left anterior upper chest wall, in multiple focal areas in bilateral lung fields, pleura and right lobe of the liver, in multiple bones and multiple lymph nodes as mentioned above, compatible with multiple metastatic lesions. Please correlate with other clinical findings for further evaluation.
    • 2020-09-22 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2017/08/01, a new lesion in the the lower T-spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
      • No prominent change is noted in the lesions in the L3-5 spines. Degenerative spine disease may show this picture.
      • A new hot spot in the lateral aspect of left rib cage and increased activity in the right femoral shaft. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and bilateral knees, compatible with benign joint lesions.
    • 2020-09-15 SONO - abdomen
      • Left liver cyst (0.66x0.78cm). Gallbladder polyp (0.18cm).
    • 2020-07-17 Gynecologic ultrasonography
      • EM 5.4mm
    • 2020-03-05 Mammography
      • S/P left mastectomy. A benign calcification in right breast.
      • BI-RADS: Category 2: benign findings.-annual screening.
    • 2020-03-05 SONO - abdomen
      • Left liver cyst (0.64x0.76cm). Gallbladder polyp (0.35cm).
    • 2019-07-06 SONO - abdomen
      • Left liver cyst (0.63x0.68cm). Gallbladder polyp (0.22cm).
    • 2018-07-10 SONO - hepatobiliary
      • Small Gallbladder polyps.
    • 2018-04-17 SONO - hepatobiliary
      • A gallbladder polyp
    • 2017-08-01 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2015/12/15, the faint hot spots in bilateral rib cages are less evident, probably more benign in nature.
      • Mildly increased activity in the L3-5 spines. Degenerative spine disease may show this picture.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and left knee, compatible with benign joint lesion.
  • consultation
    • 2022-02-21 Metabolism and Endocrinology
      • Q
        • This 58-year-old post-menopausal woman has left breast cancer (pT1cN0M0,stage:I) s/p MRM on 2008/11/14 at CGMH Linkou branch. The pathology showed invasive ductal carcinoma ,size 1.9 cm, Gr2, LN (0/41); ER(+):60%, PR(+):5%, HER2/neu(+++), FISH(-), pT1cN0M0, stage:IA.
        • She has adjuvant chemotherapy of CEF (Fluorouracil + Epirubicin + Endoxan) 6 course since 2008-12 ~ 2009-05 at CGMH Linkou branch. Then she kept Hermone therapy of Tamoxifen 10 mg/tab 1# po BID. Due to progression high level CEA 6.024 ng/ml (2012/09/10) -> 5.891 ng/ml (2012/12/10) -> 7.484 ng/ml (2013/03/4).
        • After physical examination showed no palpable nodule or mass over bil. breast with axilla regions.
        • Whole body PET scan showed
            1. a glucose hypermetabolic lesion in the left axillary region, A metastatic lesion should be considered frist;
            1. Mild glucose hypermetabolism in two right upper neck level II lymph nodes, Inflammatory process is more likely on 2013/03/26.
        • Then we arranged FNA for left axillar LN on 2013/04/05. The pathology showed positive for malignant tumor.
        • She underwent removal of left axillary soft tissue and implantation-Port A (Right) on 2013/04/26 (rTxN1M2, stage IIA).
        • Salvage chemotherapy with Taxotere *4~6 course for every three weeks was prescribed since 2013/05/13 ~ 2013/09/06. AI treatment since 2013/09/23.
        • Multiple bone mets by whole body bone scan and mulpital lung, pleural, right liver and LN mets by PET were noted on 2020/09/29.
        • CDK4/6 inhibit with Kisqali + AI since 2020/12/07. Patient hold CDK4/6 inhibit with Kisqali + AI since 2021/05 due to seeking detox therapy on her own. But tumor marker elevated.
        • After explant to patient. PIK3CA mutation (+). Faslodex + piqray was suggest.
        • Under impression of recurrent left breast cancer with multiple bone, lung, pleural, right liver and LN mets, stage IV. She was admitted for piqray 150mg 2tab QD PO.   
        • Due to hyperglycemia, we change metformin 0.5# BID to GalvusMet 1# BID and add on Tresiba 8U HS since 2022-02-11. But nausea and general weakness after GalvusMet. she hold medicine by herself. Now we need your help for medicine suggestion. Thank you so much!!
      • A
        • O:
          • F/S QDAC around 80-110
          • F/S HS around 300-400 (getting higher)
        • P:
          • Taper Tresiba to 6U HS (If F/S HS < 140, take some snack before sleep)
          • Add repaglinide 1# TIDAC, also add Trajenta 1 tab QD
    • 2022-02-12 Metabolism and Endocrinology
      • S:
        • This 58-year-old female, with past history of left breast CA s/p MRM, was admitted due to recurrent left breast cancer. We were consulted for blood sugar control.
      • O:
        • BH: 151 cm, BW: 52.7 Kg
        • Diet: normal diet
        • Medication in OPD: Metformin 0.5# BID
        • Medication during hospitalization: RI 8U ST on the night of 2022-02-10
        • Na: 137, K: 4.3
        • AST/ALT: 41/49
        • BUN/Cr: 19/0.86 (eGFR: 71.78)
        • F/S: 376/419/321
        • HbA1c: 6.1 -> 8.8
        • Urine ACR: unavailable
        • OPH OPD: no record
      • A:
        • Type 2 DM (Alpelisib and megesterol induced)
      • Suggestions:
        • Switch metformin 0.5# BID to GalvusMet 1# BID
        • Add on Tresiba 8U HS (If F/S HS < 140, take some snack before sleep)
        • Megesterol is recommended to drink a small amount regularly
        • Urine ACR can be collected in OPD later
        • Meta OPD F/U
  • surgical operation
    • 2022-03-08
      • Surgery
        • left neck tumor excision
      • Finding
        • left neck tumor 1cm
      • Procedure
        • IVGA
        • fusiform incision
        • tumor excision
        • wound closure
    • 2019-01-11
      • Malignant female breast neoplasm, NOS
      • PCS code 62009C
        • Excision of muscle or deep tissue tumoror, deep foreign body
  • chemotherapy
    • 2022-09-28 - Halaven (eribulin) 1.4mg/m2 2.22mg 5min
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-09-21 - Halaven (eribulin) 1.4mg/m2 2.22mg 5min
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-08-31 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
      • dexamethasone 4mg + metoclopramide 10mg
    • 2022-08-11 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-07-21 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-06-29 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-06-07 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-05-16 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-04-29 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-03-14 ~ 2022-05-09 - Afinitor (everolimus 10mg QD). Everolimus is an inhibitor of a kinase called mammalian target of rapamycin (mTOR)
    • 2022-03-14 ~ 2022-05-09 - Aromasin (exemestane 25mg QD)
    • 2021-03-08 ~ 2022-04-11 - Zometa (zoledronic acid, bisphosphonate) 11 cycles.
    • 2021-03-08 ~ 2022-03-07 - Faslodex (fulvestrant) 11 cycles.
    • 2020-12-07 ~ 2021-05-24 - Kisqali (ribociclib 400mg QD). There were 3 CDK4/6 inhibitors - palbociclib, ribociclib, and abemaciclib - that have been approved for HER2 metastatic breast cancers, usually in combination with hormone therapy.
    • 2017-02-20 ~ 2021-04-05 - Femera (letrozole 2.5mg QD)
    • 2013-09-23 - aromatase inhibitor
    • 2013-05-13 ~ 2013-09-06 - Taxotere (docetaxel) 4~6 course for every three weeks
    • ~ 2012? - Tamoxifen 10mg BID
    • 2008-12 ~ 2009-05 - CEF (Fluorouracil + Epirubicin + Endoxan)

[note]

  • Systemic Therapy for ER- and/or PR+ Recurrent Unresectable or Stage IV (M1) Disease - HER2-Negative and Postmenopausal or Premenopausal Receiving Ovarian Ablation or Suppression (Breast Cancer - NCCN Evidence Blocks - Version 2.2022 - December 20, 2021, p74)
    • Preferred Regimens
      • First-Line Therapy
        • Aromatase inhibitor + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) (category 1)
        • Selective ER down-regulator (fulvestrant, category 1) + non-steroidal aromatase inhibitor (anastrozole, letrozole) (category 1)
        • Fulvestrant + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) (category 1)
      • Second- and Subsequent-Line Therapy
        • Fulvestrant + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) if CKD4/6 inhibitor not previously used (category 1)
        • For PIK3CA-mutated tumors, see additional targeted therapy options
        • Everolimus + endocrine therapy (exemestane, fulvestrant, tamoxifen)
    • Other Recommended Regimens
      • First- and Subsequent-Line Therapy
        • Selective ER down-regulator
          • Fulvestrant
        • Non-steroidal aromatase inhibitor
          • Anastrozole -Letrozole
        • Selective estrogen receptors modulator -Tamoxifen
        • Steroidal aromatase inactivator -Exemestane
    • Useful in Certain Circumstancesf
      • Subsequent-Line Therapy
        • Megestrol acetate
        • Estradiol
        • Abemaciclib

==========

2023-01-10

  • The patient refused chemotherapy and began receiving Maruyama vaccine treatment (one shot by the end of 2022), an alternative therapy with few English publications (ref: PubMed, Maruyama vaccine official web site: https://www.nms.ac.jp/sh/vaccine/).
  • In most patients with persistent or recurrent symptomatic pleural effusions, repeat therapeutic thoracentesis under ultrasound guidance is generally the first-line option. Multiple sonography-guided pleural effusion tappings have been performed since 2022 with an increase in frequency over time.
  • Albumin has been prescribed appropriately to keep fluid from leaking out of blood vessels. For the purpose of removing fluid, furosemide and spironolactone have also been prescribed. Slight hyponatremia (133 mmol/L 2023-01-09) represents a relative excess of water in relation to sodium in this patient.

2022-10-13

  • Despite the use of Radi-K (potassium gluconate, since 2022-10-04) in conjunction with spironolactone (since 2022-10-10), lab data on 2022-10-13 show serum potassium at 2.7mmol/L still below normal (3.5~5.1). It is recommended to shift oral Radi-K from TID to QID or add a potassium supplement injection to prevent low K from becoming symptomatic.

2022-09-01

  • It is anticipated lower heart rate after taking Concor (bisoprolol). The patient’s heart rate increased to 107 (2022-09-01 08:48) from 86 (2022-08-31 16:38), which should be monitored.
  • The current blood pressure is normal (117/73). Concor should be held temperately if hypotension is observed.
  • Recent CXRs showed borderline cardiomegaly. It is possible to replace Concor with Coralan (ivabradine 5mg) 1# BID if the diagnosis of heart failure is confirmed (to lower the heart rate).

2022-07-22

  • The patient’s blood pressure decreased to 101/57 at 13:20 2022-07-22. If the patient’s blood pressure continues to drop and he becomes symptomatic, please DC Concor temporarily.

2022-06-30

  • The patient has recurrent breast cancer with lung and bone mets characterized by HR(+, ER+, PR-, IHC 2022-03-08) and HER2(-, DISH 2022-03-08) and is receiving docetaxel treatment since early May 2022. Prior to current regimen, mTOR kinase inhibitor everolimus and endocrine therapy exemestane have been employed during mid March to early May of 2022.
  • The chest sonography and X-ray performed in June 2022 indicated lung consolidation as well as osteosclerosis of the bones which should be kept on track in order to prevent them from becoming more symptomatic.
  • CA153 is decreasing, which is a relatively positive sign (2022-06-23 1277.8 U/mL <- 2022-04-19 4941.4 U/mL).
  • Lab data reported on 2022-06-23 indicated that liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. During this hospitalization, both TPR and BP were stable.

2022-06-08

  • CBC, WBC DC, liver and kidney function, blood electrolytes were gross normal according to lab results on 2022-05-31.
  • Low zinc level (494 ug/L, normal 700~1200ug/L, 2022-06-06) is treated with zinc gluconate currently.

700715492

230109

{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}

  • diagnosis
      1. Malignant neoplasm of ascending colon
      1. A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB
      1. Type 2 diabetes mellitus without complications
      1. Gout, unspecified
      1. Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
      1. Bipolar disorder, in partial remission, most recent episode manic
      1. Unspecified dementia without behavioral disturbance
      1. Chronic viral hepatitis B without delta-agent
      1. Essential (primary) hypertension
  • lab data
    • 2022-07-08
      • Anti-HBc Reactive
      • Anti-HBc-Value 6.99 S/CO
      • Anti-HBs 473.10 mIU/mL
      • HBsAg Nonreactive
      • HBsAg Value 0.00 IU/mL
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.10 S/CO
  • exam findings
    • 2023-01-06 Tc-99m MDP whole body bone scan
      • Increased activity in some middle and lower T-spines. Compression fractures and/or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • A hot spot in the sternum, multiple hot spots in bilateral rib cages and increased activity in the right humeral head. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
      • Mildly increased activity in the right wrist, compatible with benign joint lesion.
    • 2023-01-01 KUB plain film and L-spine lateral view
      • Compression fracture of T12.
    • 2023-01-01 CXR
      • Ground glass opacities in bil. lungs.
      • Compression fracture of T12.
    • 2022-12-26 CT - abdomen
      • Abdominal CT with and without enhancement revealed:
        • Hepatic low density lesions are found at right lobe liver up to 4.9cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-09-29, the lesions enlarged.
        • Laminated gallstone is found.
        • Visible chest
          • Nodular lesions at both lower lobes is found. Lung meta is considered. In progression.
          • S/p port-A placement with its tip at Superior vena cava
          • Borderline heart size is found.
      • Imp:
        • Ascending colon cancer, stationary in size and extension.
        • Bilateral lung and right lobe liver meta, in progression.
    • 2022-12-24 Nasal bone
      • Fracture of the nasal bone is found.
      • Regional soft tissue swelling is identified.
    • 2022-12-24 Nasopharyngoscopy
      • Scope: bil nasal cavity blood clot s/p L/T
      • smooth NPx, oropharynx, larynx
      • suspect erosion over ant. nasal cavity due to trauma
    • 2022-12-23 Bladder Sonography
      • PVR 52 mL
    • 2022-09-29 CT - abdomen
      • With and without-contrast CT of abdomen-pelvis revealed: Protocol: 4mm slice thickness, axial scan and coronal reconstruction
        • Mild regression fo A-colon cancer and liver/lung metastases.
        • Right renal angiomyolipoma (1.7cm). Bil. renal cysts (up to 1.0cm).
        • Gallbladder stones (1.5cm, 3.7cm).
      • IMP:
        • Mild regression fo A-colon cancer and liver/lung metastases.
    • 2022-06-29 CXR
      • Multiple nodules at bil. lungs.
    • 2022-06-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 18) / 75 = 76.00%
        • M-mode (Teichholz) = 76
      • Indeterminated LV filling pressure and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis and mild aortic root calcification.
      • Prominent epicardial and pericardial fat.
    • 2022-06-20 CT - abdomen
      • Findings
        • Wall thickening of cecum and proximal A-colon with adjacent fat stranding and reginal LAP. Multiple liver and lung metastases.
        • Right renal angiomyolipoma (1.7cm). Bil. renal cysts (up to 1.0cm).
        • Gallbladder stones (1.5cm, 3.7cm).
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
    • 2022-06-20 KUB
      • Presence of radiopaque gallbladder stones.
      • Degeneration and spondylosis of L-S spine.
    • 2022-06-17 Patho - colon biopsy
      • Intestine, large, ascending colon, biopsy — adenocarcinoma
      • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands lined by high-grade dysplastic cells and focal stromal invasion with desmoplasia. The tumor cells display hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic figures.
      • IHC stain — EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
    • 2022-06-16 ECG
      • Left axis deviation
      • Nonspecific T wave abnormality
    • 2022-06-16 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • EM: 3.5mm
    • 2022-06-16 Colonoscopy
      • Diagnosis
        • Highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization
        • Mixed hemorrhoids
      • Suggestion
        • OPD F/U
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2022-06-16 Pulmonary bronchodilator test
      • Moderate restrictive ventilatory impairment with significant bronchodilator response suspected poor effort related
      • please correlated with clinical condition
    • 2021-12-23 KUB + L-spine Lat
      • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
      • Presence of spondylolisthesis at L4/5, grade I.
    • 2021-09-22 CT - brain
      • IMP: General brain atrophy. Hydrocephalus.
    • 2021-09-07 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Inferior infarct , age undetermined
      • Possible Anterior infarct , age undetermined
      • Abnormal ECG
    • 2018-05-05 SONO - abdomen
      • Diagnosis
        • fatty liver, moderate
        • incomplete exam of liver gallstone
      • Suggestion
        • suboptimal exam of liver because of subcutaneous fat and liver fatty change
        • suggest F/U
    • 2018-02-24 KUB
      • Degenerative change of the thoracic and lumbar spine with spurs formation/scoliosis and narrowed intervertebral disc spaces.
      • Presenc of radiopaque oval or round density in right upper abdomen, c/w gallbladder stone(s).
    • 2018-01-22 KUB
      • Presence of radiopaque gallbladder stones.
    • 2017-02-15 T-spine AP + Lat.
      • s/p VP in the T7 vertebral body with bone cement extravasation.
    • 2017-01-05 T-spine AP + Lat.
      • mild scoliosis of the T-spine.
      • s/p VP in the T7 vertebral body
  • consultation
    • 2023-01-06 Psychosomatic Medicine
      • Q
        • This 70-year-old woman patient suffered from Stool OB (LIA) = Positive and Occultblood (LIA) > 999 ng/mL on 2022/05/31. No abdominal pain, tarry stool passage and body weight loss was noted. Colonoscopy on 2022/06/16 showed highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization and mixed hemorrhoids. Pathology showed adenocarcinoma, IHC stain - EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+). Abdominal CT on 2022/06/20 showed A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB. Tumor mark on 2022/06/21 with CA-199 showed 15056.5 U/ml, CEA showed 995.6 ng/ml. 2D echo on 2022/06/23 showed 1.Indeterminated LV filling pressure and impaired RV relaxation. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis and mild aortic root calcification. 4.Prominent epicardial and pericardial fat. Port-A catheter insertion on 2022/06/29.
        • Palliative chemotherapy with FOLFIRI (Campto 150mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/07/12(C1D1), 2022/07/22(C1D15), 2022/08/05(C2D1), 2022/08/17(C2D15), 2022/08/30(C3D1).2022/9/29(C4D1).2022/10/12(C4D15).2022/10/26(C5D1).2022/11/9(C5D15).2022/11/23(C6D1).2022/12/7(C6D15).2022/12/21(C7D1).
        • Target therapy with Avastin(5mg/kg) was given on 2022/08/30(C1), 2022/09/13(C2), 2022/9/29(C3), 2022/10/12(C4), 2022/10/26(C5), 2022/11/9(C6), 2022/11/23(C7), 2022/12/7(C8), 2022/12/21(C9).
        • Followed up CT was performed on 2022/12/26 revealed Ascending colon cancer, stationary in size and extension. Bilateral lung and right lobe liver meta, in progression.
        • The patient present urinary frequency with interval of 1-2 hour since about one week ago. Urgency urinary incontinence was noted, but no stress urinary incontinence. She also had nocturia every 0.5-1 hour at night with small amount urine. Bilateral flank pain developed for days. Otherwise, she denied cough, rhinorrhea, short of breath, diarrhea, abdominal pain, or chest tightness. Due to mentioned symptoms, she came to our hospital for help.
        • At ER, her vital signs revealed BP:151/83mmHg; HR:100bpm; BT:36.2 degrees Celsius; RR:16/min; GCS:E4V5M6. Lab data revealed leukocytosis, normocytic anemia, elevated CRP and lactic acid. Urine analysis showed pyuria and bacteuria. CXR revealed ground glass opacities in bil. lungs and compression fracture of T12. Under the impression of urinary tract infection, the patient was admitted for further evaluation and management.
        • We had explained the current condition to family and patient still had depressed mood, we need your expertise for further management, thanks 
      • A
        • Acute depressive state
          • suspected adjustment reaction with depressive features
          • suspected bipolar disorder, current episode depressed
        • Symptoms and course:
          • This is a 70 y/o female patient admitted under the impression of urinary tract infection, colon cancer with lung and liver metastasis. We were consulted for fer depressed mood.
          • According to the patient and her family, she recently was informed of the progression of her own disease; therefore, she showed more prominent depressed mood and also transient suicide ideation without plan.
          • She claimed that she would got occasional negative ideation, preoccupied over the condition of her cancer, with hopeless andhelpless feelings; while she also said that she could try to cope with the feelings by sharing them with her family.
          • She denied current suicide ideation or plan.
        • Suggestion:
          • Give depakine 200mg/tab 1# QD + 500mg/tab 1# HS, add zyprexa(5mg) 1# HS
          • Suicide risk assessment: low to moderate, transient idea, family support (+), no organised plan
          • Provide emotional catharsis, and psychoeducation for suicide risk prevention
          • Monitor her mood condition during admission, prevent suicide
          • Arrange PSY OPD f/u
    • 2023-01-04 Hemato-Oncology
      • Q
        • A case of Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis s/p palliative chemotherapy, the last biochemotherapy with Avastin plus FOLFIRI was administered on 2022/12/21
        • This time, the patient present urinary frequency with interval of 1-2 hour since about one week ago. Urgency urinary incontinence was noted, but no stress urinary incontinence. She also had nocturia every 0.5-1 hour at night with small amount urine. Bilateral flank pain developed for days. Otherwise, she denied cough, rhinorrhea, short of breath, diarrhea, abdominal pain, or chest tightness. Due to entioned symptoms, she came to our hospital for help.
        • At ER, her vital signs revealed BP:151/83mmHg; HR:100bpm; BT:36.2 degrees Celsius; RR:16/min; GCS:E4V5M6. Lab data revealed leukocytosis, normocytic anemia, elevated CRP and lactic acid. Urine analysis showed pyuria and bacteuria. CXR revealed ground glass opacities in bil. lungs and compression fracture of T12. Under the impression of urinary tract infection, the patient was admitted for further evaluation and management. Owing to patient requested, we need your expertise for further management, thanks
      • A
        • This 69 year old woman is a case of Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis s/p palliative chemotherapy. She was admited due to UTI. We may take over if you agree. Thanks for your consultation.
    • 2023-01-03 Family Medicine
      • Q
        • Her family prefered palliative care and decided DNR.
        • We need your expertise to evaluate for palliative caer, sincerely thanks.
      • A
        • 69-year-old female, Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis
        • Consciousness clear, ECOG 3
        • We will arrange hospice combine care and follow her condition
        • Indication: Ascending colon cancer
        • Plan: Combined Hospice Care
    • 2022-12-24 ENT
      • A
        • Epistaxis after falling down, mild NO,
          • the patient claimed that she fainted before falling
        • O:
          • Scope: bil nasal cavity blood clot s/p L/T
          • smooth NPx, oropharynx, larynx
          • suspect erosion over ant. nasal cavity due to trauma
        • A:
          • Bil epistaxis, anterior
        • Plan:
          • s/p local treatment
          • Allegra, transamin if no contraindication
          • Education done, if bleeding again, compression ant. nose for at least 20 mins with head downward and mouth open, if still bleeding, back to hosspital soon
          • ENT OPD f/u
  • chemoimmunotherapy
    • 2022-12-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-12-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-23 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-09 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-10-26 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-10-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-09-29 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-2
    • 2022-08-30 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 230mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-2
    • 2022-08-17 - irinotecan 120mg/m2 200mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-08-05 - irinotecan 90mg/m2 150mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1
    • 2022-07-22 - LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr (standard)
      • dexamethasone 4mg + metoclopramide 10mg
    • 2022-07-12 - LV 300 mg/m2 500mg 2hr + 5-FU 300 mg/m2 500mg 10min + 5-FU 2000 mg/m2 3300mg 46 hr (75% dose)
      • dexamethasone 4mg + metoclopramide 10mg

==========

2023-01-09

  • The results of the culture have not yet been released.
  • UTI is currently managed with empirical Cefepime 2g Q8H (not for ESBL risk; ESBL = extended spectrum beta-Lactamase).
  • If VRE or MRSA are suspected (eg, based on prior isolates), vancomycin (for MRSA) or daptomycin or linezolid (for VRE) might be added.

[tube feeding]

  • The patient-carried Depakine Tablet (valproic acid 500mg) package insert instructs “not to crush or chew the tablet.”
  • To replace Depakine Tablet 500mg HS, it is recommended to use Depakine Solution (sodium valproic 200mg/mL, 40mL/bt, available currently in stock) 2.5mL HS.
  • As the liver and kidney function of the patient have not declined (2023-01-05 and 2023-01-09 lab data), there is no need to adjust the dose.

2022-09-30

  • After adding irinotecan to the regimen in early Aug 2022, the levels of CEA and CA199 have been cut in half since the last month indicated that the treatment was working.
    • 2022-09-16 CEA 1085.5 ng/ml
    • 2022-08-19 CEA 1873.6 ng/ml
    • 2022-07-26 CEA 1895.2 ng/ml
    • 2022-09-16 CA-199 6337.5 U/ml
    • 2022-08-19 CA-199 15268.5 U/ml
    • 2022-07-26 CA-199 15964.6 U/ml
  • The patient with type 2 diabetes is currently on Galvus Met (vildagliptin (DPP4i) + metformin (biguanide)) with blood sugar levels over 180 mg/dL as recorded on 2022-09-29 and 2022-09-30.
  • The initialization of SGLT2i Canaglu (canagliflozin 100mg) QDAC, Forxiga (10mg) QD, or Jardiance (empagliflozin 25mg) QD might be an option in the event of consecutive 2 or 3 data points over 200 mg/dL.

2022-08-31

  • 2022-08-19 CEA 1873 ng/mL and CA199 15268 U/mL remained high. 2022-08-30 lab data indicated grossly normal liver and kidney function, serum electrolytes, and CBC.
  • The patient has been diagnosed with hypertenstion. The blood pressure records during this hospitalization were 113~138 / 59~75, not excessive for the time being. This is the first time the patient receiving bevacizumab, which is associated with a high incidence of hypertension (24% to 42%), so close monitoring is recommended.

2022-07-25

  • 2022-06-23 2D transthoracic echocardiography showed: 1. Indeterminated LV filling pressure and impaired RV relaxation; 2. Normal LV and RV systolic function; 3. Mild aortic valve sclerosis and mild aortic root calcification. The initial dose of LV + 5-FU was set at 75% of the standard dose.
  • The patient has been prescribed Depakine (valproate) 700mg daily by our psychosomatic medicine OPD for her bipolar disorder since Jan 2017. Well-tolerated.
  • The patient has been prescribed Euricon (benzbromarone) 50mg daily by our cardiology OPD for her hyperuricemia since Mar 2017. In accordance with the every helf-year laboratory data, her uric acid levels were all within normal ranges from 2020-11 to 2022-04.
  • Blood sugar levels were slightly elevated during this hospitalization, ranging from 110 to 253 mg/dL. In spite of this, there were no two consecutive days with glucose levels over 200 mg/dL, so it might not be necessary to adjust the hypoglycemic medication.

2022-07-13

  • The patient’s HbA1c were 7 +- 0.4%, serum glucose AC were 160 +- 30 mg/dL in the last three years, slightly above normal, a more intensive intervention might not be necessary if there is no urgency.
  • TPR, BP remain stable during this hospitalization.
  • In patients with moderate dementia (CDR = 2), Witgen (memantine 10 mg/tab) might be considered as an optional add-on.

700089206

230106

  • diagnosis - 20230105 admission note
    • Malignant neoplasm of colon, unspecified
    • Fever, unspecified
    • Malignant neoplasm of sigmoid colon
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Gastrointestinal hemorrhage, unspecified
  • family history
    • The patient has very strong family history of colon caner, from the father’s side.
  • exam findings
    • 2023-01-05, 2022-12-23 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Possible Inferior infarct, age undetermined
      • Anterolateral infarct, age undetermined
      • Abnormal ECG
    • 2022-12-23 CXR
      • Hypoinflation of both lung is noted.
    • 2022-12-21 CT - brain
      • No evidence of intracranial lesion.
    • 2022-12-21 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
      • normal motor DLs, CMAP amplitudes and NCVs of bil. median, ulnar, peroneal and tibial n.
      • normal sensory DLs, SNAP amplitudes and NCVs of bil. median, ulnar, and sural n.
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
      • the H-reflex study of bil. tibial n. were normal
    • 2022-12-14 CT - abdomen
      • History: 20220914 CT: sigmoid colon cancer, cT4aN2aM1b (liver and non-regional LNs metastases)
      • Findings: Comparison: prior CT dated 2022/09/14.
        • Prior CT identified segmental asymmetrical wall thickening at the sigmoid colon with irregular contour is noted again, stable in wall thickness except poor enhancement that that is c/w adenocarcinoma of the sigmoid colon S/P C/T with partial response.
        • Prior CT identified metastatic nodes in the adjacent mesocolon are noted again. Most of them show decreasing in size. However, the largest one 4 cm in size shows increasing in size to 5.5 cm that is c/w progressive disease.
        • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size and number that are c/w progressive disease.
        • Prior CT identified several metastatic nodes in the celiac trunk and hepatoduodenal ligament are noted again, mild increasing in size that are c/w progressive disease.
        • There are soft tissue lesions in the liver hilum and ligamentum teres that may be metastatic nodes or lymphedema?
        • The gallbladder shows marked edematous wall thickening that may be hypoalbuminemia.
        • There is ascites in the abdomen and pelvis and suggestive small soft tissue nodules in the omentum and mesentery.
          • Please correlate with ascites cytology to evaluate if there is carcinomatosis?
          • In addition, There is splenomegaly (the greatest anterior-posterior dimention 15 cm).
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
        • Others
          • There is no focal abnormality in the biliary system and pancreas.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Adenocarcinoma of the sigmoid colon with LNs and liver metastases S/P C/T show progressive disease.
    • 2022-09-22 Patho - stomach biospy
      • Stomach, body, AW, biopsy — Fundic gland polyp
    • 2022-09-22 Panendoscopy
      • Reflux esophagitis, lower esophagus, LA classification, grade A
      • Superfical gastritis, antrum
      • Gastric polyp, body, AW, s/p biopsy
    • 2022-09-21 All-RAS + BRAF mutations assay
      • All-RAS mutations assay
        • Detection range
          • KRAS codon 12, 13, 59, 61, 117, 146
          • NRAS codon 12, 13, 59, 61, 117, 146
        • Results
          • There was no variant detected in the KRAS/NRAS gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
      • BRAF mutations assay
        • Detection range
          • BRAF codon 600
        • Results
          • There was no variant detected in the BRAF gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • 2022-09-20 KUB
      • There is vas deferens calcification. Please correlate with serum glucose to R/O DM.
      • Fecal material store in the colon.
    • 2022-09-17 CT - chest
      • Indication: This is a 39-year-old male who was newly diagnosed colon cancer stage IV (with liver metastasis), we would like to arrange him a lung CT, in order to rule out lung metastasis.
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Subpleural nodule at right upper lobe up to 0.2cm in largest dimension is found. Benign process is favored.
          • No evidence of bilateral pleural effusion.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
        • Visible abdomen:
          • Low density lesions at both lobes of liver are found. Liver meta is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • Suggest clinical correlation
      • Imp:
        • Diffuse liver meta.
        • No evidence of pulmonary meta in the study.
    • 2022-09-14 CT - abdomen
      • History:
        • Passing bloody stool since last week asssociated with left upper quadrant pain.
        • 20220912 sigmoidoscopy: An ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon.
      • Indication:
        • sigmoid colon cancer for staging
      • Findings:
        • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
          • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
        • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
          • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
        • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
    • 2022-09-13 Patho - colon biopsy
      • Intestine, large, sigmoid colon, biopsy — adenocarcinoma
      • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(-), MSH2(+), MSH6(+)
      • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • 2022-09-12 Sigmoidoscopy
      • Diagnosis
        • Probable sigmoid colon cancer, s/p biopsy
        • Hemorrhoid
        • Incomplete study of colon
      • Suggestion
        • Total colonoscopy is impossible due to the luminal stenosis caused by the tumor.
        • Pursue pathology result
        • Consider CT scan for further investigation
      • Complication
        • No immediate complication
    • 2020-10-30 SONO - abdomen
      • Diagnosis
        • Fatty liver, moderate
        • GB polyp
        • suspicious, Renal stone, right
        • Renal cyst, left
        • pancreatic body and tail masked by gas.
      • Suggestion
        • encourage exercise and diet adjustment.
        • Visit Urology if symptoms revealed.
    • 2020-10-16 SONO - nephrology
      • Left renal cysts
      • Left renal stone
  • consultation
    • 2022-12-20 Neurology
      • Q
        • This is a 40-year-old male underlying colon cancer with multiple liver metastasis, cT4N2aM1b. This time, he came to our emergency room due to fever with chills off and on for three days. He was admitted for infection control and further chemotherapy. During admission, he complaint about dizziness, general weakness, and unstable gait. We need your help for further evaluation. Thank you very much.
      • A
        • dizziness, unsteadiness esp. while standing up and walk for steps, tilting at times, but the symptoms progressed for longer times after each chemotherapy
        • NE: aware, fluent speech, normal cranial nerves, no obvious focal weakness, diffuse hypo-reflexia, bil. thigh and girdle muscle atrophy, no obvious tenderness
        • Impression:
          • suspect cancer related myopathy and neuropathy, also dysautonomia
        • Suggest:
          • brain CT and nerve conduction study (motor and sensory NCV, H-reflex, F-wave) might be arranged
          • I would like to follow up this patient. Thank you for your consultation.
    • 2022-09-15 Hemato-Oncology
      • Q
        • The patient had strong family history of colon cancer from the father’s side.
        • Ealier of the day, CT report shows as follow:
          • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
            • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
          • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
            • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
          • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
          • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
          • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value).
        • Consider the patient and his family are eager to engage into further treatment, we’d like to cousult with oncologists, with your expertise, we will have better insight of the future treatment for the patient (Whether the patient should go under what kind of chemotherapy)
        • We know Dr. Wan is very occupied today, please evaluate the patient at your free time, appreciate.
      • A
        • This 39 year old man is a case of sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Initially presentation is bloody stool. Besides, he has family history of colon cancer from the father’s side. Signoid colonscopy show an ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon. Further insertion failed due to luminal stenosis. We are consulted for further evaluation.
        • Impression:
          • Favor sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Wait pathology. CEA pending.
        • Suggestion:
          • Consult CRS for operation or stenting evaluation due to impending luminal stenosis.
          • Systemic chemotherapy is indicated for metastasis colon cancer (for palliative or down stage). Arrange port A insertion, if patient agree further treatment. In addition, may consider clinical trial if avialable. Please check All-RAS + BRAF assays.
          • Check HbsAg, Anti-Hbc, Anti-HCV before chemotherapy. Arrange chest CT (+/-contrast) for complete work up r/o lung meta
          • We wound like to folluw up this case. If there is any problem, please feel free to let us known.
    • 2022-09-13 Colorectal Surgery
      • Q
        • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry, stool routine and image were performed. Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy; Hemorrhoid. Under the tentative diagnosis of Propable colon tumor, S colon, the patient was admitted for further evaluation and treatment. So we need your expert for colon tumor, S colon further Tx. Thanks!
      • A
        • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry,stool routine and image were performed.Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy ;Hemorrhoid.Under the tentative diagnosis of Propable colon tumor,S colon,the patient was admitted for further evaluation and treatment.So we need your expert for colon tumor,S colon..
        • A: Tumor of S-colon with lumen narrowing
        • P:
          • Waiting CT result
          • Surgical intervention with laparoscopic colectomy is indicated
          • We will visit this patient soon
  • chemotherapy
    • 2022-12-07 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 160mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5100mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
    • 2022-11-16 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
    • 2022-11-02 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-10-19 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-10-05 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-09-19 - cetuximab 400mg/m2 800mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 430mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5800mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

==========

2023-01-06

  • According to the updated lab data (2023-01-06 05:55), the serum potassium level has returned to normal (3.8 mmol/L), and the potassium supplement might be slowed down or held temperarily if there is no continuous leakage suspected.

2022-12-15

  • 2022-12-13 WBC 15.23 *10^3/uL, CRP 8.15 mg/dL, the infection signs are treated with Brosym (cefoperazone + sulbactam) without an issue.

700962042

230106

  • exam finding
    • 2022-11-20 CT - abdomen
      • Clinical history: 53 y/o female patient with ovary cancer with peritonal seeding
      • With and without contrast enhancement CT of abdomen–whole:
        • S/P hysterectomy.
        • Outpouching lesion in ascending colon, suggesting ascending colon diverticulum.
      • Impression:
        • S/P hysterectomy. Suggest follow up.
        • Ascending colon diverticulum.
    • 2022-08-10 CT - abdomen
      • History: ovarain cancer, s/p neoadjuvant bidirectional chemotherapy (IP with Taxotere/Cisplatin x 3 cycles, IV with Taxol/Carboplatin x 4 cycles).
      • Indication: ovary cancer with peritonal seeding S/P HIPEC for FU
      • Impression:
        • S/P hysterectomy. There is no evidence of tumor recurrence.
    • 2022-08-10 CXR
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
    • 2022-06-27 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (163 - 50) / 163 = 69.33%
        • M-mode (Teichholz) = 69
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA
      • Trivial MR, trivial AR, mild to moderate TR
      • Preserved RV systolic function
    • 2022-06-20 CT - chest
      • Comparison was made with previous CT dated on 2021 2022
        • Lungs:
          • Platelike lung atelectasis over Rt middle lobe
          • subtle mosaic pulmonary attenuation in both lungs
        • Mediastinum and hila: no enlarged LN or mass.
        • Vessels: mild coronary arterial calcification.
          • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
          • Central pulmonary arteries: normal caliber.
      • Impression:
        • suspect small airways disease involving both lungs d/d drug treatment related change.
    • 2022-02-09 CT - abdomen, pelvis
      • S/P hysterectomy. There is no evidence of tumor recurrence.
    • 2021-10-08 Patho - peritoneum biopsy
      • diagnosis
        • Peritoneum, left lower, cytoreductive surgery - Serous carcinoma, seeding
        • Appendix, cytoreductive surgery - Serous carcinoma, seeding
        • Peritoneum, right flank, cytoreductive surgery - Serous carcinoma, seeding
        • Omenum, cytoreductive surgery - Serous carcinoma, seeding
        • Peritoneum, right upper, cytoreductive surgery - Serous carcinoma, seeding
        • Gallbladder, cytoreductive surgery - Serous carcinoma, seeding
      • IHC: WT-1(+), CK7(+), CK20(-), PAX-8(+)
    • 2021-10-08 Patho - uterus neoplastic
      • diagnosis
        • Ovary, bilateral, salpingo-oophorectomy (s/p chemotherapy) - Serous carcinoma, high-grade
        • Fallopian tube, bilateral, salpingo-oophorectomy - Serous carcinoma, seeding
        • Uterus, serosa, abdominal total hysterectomy - Serous carcinoma, seeding
  • consultation
    • 2022-06-25 Chest Medicine
      • Q
        • for dyspnea & pneumonia over both lungs
        • for intermittent fever for one more ago
        • This 52 y/o female, a pt of ovarian CA wt peritoneal seeding Dx in April 2021, s/p pre-Op neoadjuvant IV C/T wt Taxol / Carboplatin concurrently wt IP C/T wt Taxotere / Cisplatin Q3W x 3 (Bidirectional C/T, intraperitoneal-systemic C/T) from May 2021 to July 2021 & #4 IV Taxol / Carboplatin on 20210901 & Bil, salpingo-oophorectomy & cytoreductive surgery & HIPEC on 20211007. She was admitted due to high fever and dyspnea and cough for 2 days. CXR showed pneumonia over both lungs. We need expertise to evaluate her condition thanks!
      • A
        • CxR
          • Lung markings: increased density in the bilateral lower lung fields, in progression
        • CT
          • Platelike lung atelectasis over Rt middle lobe
          • subtle mosaic pulmonary attenuation in both lungs
            • suspect small airways disease involving both lungs d/d drug treatment related change.
          • Imp
            • Bilateral pneumonia, r/o pneumonitis, pathogen?
        • Suggestion
          • Check PJP (done), CMV (done), atypical pathogens (done), TB*3, Cryptococcus, Aspergillus
          • May add IV medason 0.5amp Q12H and taper when condition inproved
          • Keep tapimycin + Targocid, may add Cravit if CxR progression
          • F/U CxR on 20220625 and closely (CXR, BT improved on 20220625)
          • Keep I/O balance, electrolyte balance. correct anemia
          • Arrange 2D for heart function survey
          • Check Alb next time
          • follow up lab and CXR days later
          • If condition still progression with unstable O2 saturation, intubation with ICU admission and bronchoscope with full work-up survey might be needed
    • 2021-10-08 Chest Medicine
      • Q
        • She was admitted and received 3 combined surgery
          • right upper, right flank and left lower peritonectomy, appendectomy, cholecystectomy
          • abdominal total hysterectomy + bilateral salpingooophorectomy
          • bilateral URS-exam and ureteral catheterization on 20211007.
        • Post-op he was transferred to SICU for intensive care.
        • Cruuent problem:
          • right lung pleural effusion
        • We need your epertise for evaluation. Thanks a lot.
      • A
        • Right side pleural effusion abruptly expressed due to
          • elevated hydrastatic pressure
          • Major abdominal operation
        • Suggestion
          • we will arrange chest echo for pig-tail insertion
          • reduce hydrastatif fluid infusion
          • Lasix to keep I/O negative
          • High risk of kidney injury due to multiple nephrotoxic agents use
          • delay extubation till right pleural effusio drained out.
          • Enteral feeding as soon.
          • Thanks and f/u prn.
    • 2021-04-17 Hemato-Oncology
      • Q
        • The 55 y/o female, a pt wt suspected ovarian CA or gastric CA wt peritoneal mets Dx in April 2021.
        • PH:
          • Hypertension under medical control for years.
          • Tachycardia treated with propanolol.
          • HBV.
        • She suffered from left upper abdominal pain since 20210403
        • Her abdominal pain aggravated when she is eating, drinking and lying on the left side. She also had abdomen fullness and nausea for one month, denied of body weight loss. At ER, abdomen echo showed massive ascites, then tapping was done.
        • Abd CT showed ascites and peritoneal soft tissue density, suspected peritoneal carcinomatosis, suspect wall thickening of gastric antrum.
        • Under the impression of spontaneous bacteria peritonitis with hollow organ perforation, she was admitted to GI ward for management on 2021/04/08.
        • GS was consulted for suspected hollow organ perforation, and suggested exploratory laparascopy. She underwent operation of laparoscopic peritoneal tumor excision and PD tube implantation (Ascites amount: 8000ml) on 20210412.
        • CA-125: 496.8, normal CEA, CA-199.
        • Ascites cytology: malignancy. Pathology revealed Metastatic serous carcinoma,
          • IHC the tumor cells shows: CK7(+), CK20(-), CK5/6(-), WT1(+), and PAX8 (+).
        • Bidirectional C/T. We need your expertise for suspect ovarian cancer with peritoneal metastatic evaluation and thanks for your times.
      • A
        • Lab:
          • Peritoneum, laparoscopic peritoneal biopsy (20210413): Met serous carcinoma.
        • Abd CT (20210407):
          • Extraluminal air; DDx: hollow organ performation, previous peritoneocentesis
          • Ascites and peritoneal soft tissue density, r/o peritoneal carcinomatosis
          • Suspect wall thickening of gastric antrum
        • EGD & colonscopy will be done.
        • Medical advice:
          • It is most likely that the pt suffered from ovarian CA wt peritoneal seeding if EGD & colonoscopy shows negative.
          • If the pt accepts aggressive Tx for peritoneal mets, may consider bidirectional systemic IV C/T plus intra-peritoneal (IP) C/T.
        • No standard treatment for peritoneal carcinomatosis (PC) from colon or gastric cer. Peritoneal cavity acts as a sanctuary against systemic C/T probably because of the existence of a blood peritoneal barrier consisting of stromal tissue between mesothelial cells and submesothelial blood capillaries.
          • Only a small amount of systemic drugs are capable of penetrating this barrier and passing into the peritoneal cavity (eg: 5-FU, paclitaxel, docetacel, gemcitabine, doxorubicin).
          • IP chemotherapy offers potential therapeutic advantages over systemic chemotherapy by generating high local concentrations of chemotherapeutic drugs in the peritoneal cavity. This concentration difference enables the exposure of small nodules of PC before cytoreductive surgery ( CRS ) and lowers the systemic toxicity.
        • Bidirectional IV / IP C/T first then do Op. Tx schedule as following:
          • multidisciplinary treatment combining Bidirectional C/T:
            • Neoadjuvant intraperitoneal-systemic C/T protocol (NIPS),
          • Peritonectomy & Gyn Op.
          • Hyperthermic intraperitoneal chemoperfusion (HIPEC)
          • Early postoperative intraperitoneal C/T (EPIC).
        • Aims of NIPS are stage reduction, the eradication of peritoneal free cancer cells, and an increased incidence of complete cytoreduction (CC-0) for PC.
        • Early postoperative intraperitoneal chemotherapy (EPIC) can eradicate residual intraperitoneal cancer cells before fibrin can accumulate around residual cancer cells on the peritoneal surface.
        • The current state-of-the-art treatment for colorectal peritoneal dissemination CRS (cytoreductive surgery) & HIPEC.
        • Pt wt low tumor volume, well/mod. differentiated tumors and complete cytoreduction may potentially benefit from CRS & HIPEC.
        • CRS wt peritonectomy plus HIPEC confers a prolonged survival. Complete cytoreduction is an essential factor for a good outcome.
        • NIPS plus peritonectomy may improve the incidence of complete cytoreduction.
          • ref: J Clin Oncol 2004; 22: 3284-3292 & J Surg Oncol 2009; 100: 311-316 )
        • Peritoneal wash cytological examination was performed before and after NIPS & other intraperitoneal chemotherapy.
        • Systemic IV chemotherpay wt Taxol / Carboplatin concurrently wt IP C/T wt Taxotere / Cisplatin Q3W x 4 (Bidirectional C/T, intraperitoneal-systemic C/T). Then will do abd CT for response evaluation.
  • surgical operation
    • 2021-10-07 total hysterectomy + bilateral salpingo-oophorectomy
  • chemotherapy
    • 2023-01-06 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-12-12 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2022-11-21 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2023-10-31 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-10-14 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2022-09-19 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2023-08-09 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-07-19 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2022-06-07 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2023-05-16 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-04-18 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2022-03-23 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2022-03-01 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
      • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg
    • 2022-02-07 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2022-01-17 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-12-27 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-12-06 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-11-12 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-10-07 - [cisplatin 75mg/m2 142mg + docetaxel 60mg/m2 114mg + gentamicin 40mg + sodium bicarbonate 4200mg] ST IP 90min (the surgical operation day)
    • 2021-09-02 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 440mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-07-06 - paclitaxel 100mg/m2 185mg 3hr + carboplatin AUC 5 540mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-06-02 - paclitaxel 100mg/m2 190mg 3hr + carboplatin AUC 5 600mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 56mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-05-04 - paclitaxel 100mg/m2 190mg 3hr + carboplatin AUC 5 435mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 56mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg

==========

2023-01-06

  • As a result of anemia, the patient received blood transfusion of LPRBC and was discharged on 2023-01-06 under stable conditions.

2022-03-02

  • platin-based regimen has been introduced since May 2021, bevacizumab added since Nov 2021 s/p total hysterectomy + bilateral salpingo-oophorectomy, most recent CT on 2022-02-09 showed no evidence of tumor recurrence. no issue with current medication.

701432080

230106

[OxyNorm tube feeding]

  • The package insert of OxyNorm (oxycodone 5mg) instructs “Do not chew or crush them.”
  • For NG feedings or gastrostomies, add some water to the tube, open the capsule and pour the contents directly into the tube, then rinse the tube with 15mL of water, then another 10mL of water, several times. In addition to water, milk or liquid nutrition can also be used.

[no sodium version of piperacillin + tazobactam]

  • Cefim (cefepime) and Pipe&Tazo (piperacillin + tazobactam) cover overlapping spectrum of micromials. However, the former is a hydrochloride salt, which should not increase the sodium levels in the body, while the latter is sodium-based.
  • As this patient is 77 years of age, weighs 50kg, and has a creatinine level of 1.97 mg/dL, the estimated CrCl is 22mL/min, it is recommended that cefepime should not exceed 2g once daily.
  • When possible, bacterial culture should still be performed to confirm the pathogen and limit the scope of antibacterial treatment.

701465162

230106

  • diagnosis
    • Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission
  • present illness - 20221228 admission note
    • This is a 61-year-old male with the past history of DM under diet control, hypertension without medication control, monomorphic epitheliotropic intestinal T-cell lymphoma s/p ileocecectomy, small bowel resection, end ileostomy on 2022/11/25. He lived in America and received surgical and medication treatment there, he came back to Taiwan on 2022/12/25. This time, he came to our hematology and oncology outpatient department for further evaluation and treatment. According to the patient, he sufferred from abdominal discomfort for almost four months, especially after meal. Accompanied with poor appetite, nausea, vomiting, and dizziness. Intermittent chest tightness and mild dyspnea without radiation pain nor cold sweating was also mentioned. He lost about 10 kilograms in the recent three months. There was no fever, no chills, no dysuria, no tarry stool. Under the impress
  • past history
    • DM under diet control
    • HTN without medication control
    • Monomorphic epitheliotropic intestinal T-cell lymphoma s/p ileocecectomy, small bowel resection, end ileostomy on 2022/11/25
  • family history
    • His father has peritoneal cancer.
    • His mother has cervical cancer and hypertension.
    • His sister has lung cancer.
    • His brother has thyroid cancer.
  • lab data
    • 2022-12-28 Anti-HBc Reactive
    • 2022-12-28 Anti-HBc-Value 6.64 S/CO
    • 2022-12-28 Anti-HCV Nonreactive
    • 2022-12-28 Anti-HCV Value 0.20 S/CO
    • 2022-12-28 HBsAg Nonreactive
    • 2022-12-28 HBsAg (Value) 0.45 S/CO

2023-01-06

[tube feeding]

It is possible to peel the Concor (bisoprolol 1.25mg) tablet in half or grind it for tube feeding.

2022-12-29

  • High bilirubin (total and direct), AST, ALT; slightly high Glucose (AC), HbA1c; slightly low serum Na, K have been seen in lab data on 2022-12-28/29.
  • There is no past history of hypercholesterolemia or available laboratory data to support this condition, Tulip (atorvastatin) might not be indicated.

700976532

230104

  • past history - 20221229 admisstion note
    • Hypertension
    • Hepatocellular carcinoma (stage unknown) status post partial hepatectomy 8 years ago in RenAi Hospital.
  • exam findings
    • 2023-01-04 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (145 - 27) / 145 = 81.38%
        • M-mode (Teichholz) = 81
      • Mild biventricular hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
      • Dilated LV with normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR; mild TR.
      • Possible mild to moderate pulmonary hypertension (the estimated systolic PA pressure 53 mmHg).
      • Moderate amount pericardial effusion (100-200 ml) without signs of tamponade
    • 2022-12-31 MRI - L-spine
      • Findings
        • Diffuse bone marrow fat replacing disease was seen, seen as abnormal low signal intensity on T1WI.
        • Multiple nodular bone destructing masses also were noted, up to 23 mm in size at posterior body of L1.
        • A right body mass was found at T2.
        • After IV contrast administration shows well or heterogenous enhancement of the masses or tumors.
        • However, no obvious dural sac or spinal cord compression was found.
      • IMP:
        • Diffuse bone marrow fat replacing disease at bil. pelvic bones, thoraco-lumbar spine, with sloid masses or nodules (myelomas) as described above.
    • 2022-12-29 CT - abdomen
      • Findings
        • Multiple osteolytic lesions in ribs, spine and pelvic bones.
        • Hyperplasia of left adrenal gland.
        • Wall thickening of rectum.
        • Tiny gallbladder stones.
        • Pericardial effusion.
        • Atherosclerosis of aorta, iliac, coronary arteries.
        • Right pleural effusion.
      • IMP:
        • Multiple osteolytic lesions in ribs, spine and pelvic bones. DDX: metastases, multiple myeloma.
        • Wall thickening of rectum.
    • 2022-12-29 ECG
      • Normal sinus rhythm
      • Right bundle branch block
      • Left anterior fascicular block
      • Bifascicular block
      • Abnormal ECG
    • 2022-12-29 Pelvis-THR and Lt. Hip Lat
      • Destruction at left iliac bone, r/o bone metastasis.
    • 2022-12-29 L-spine AP + Lat. (including sacrum)
      • Lumbar spondylosis.
      • Maintained bony alignment.
      • Atherosclerosis of abdominal aorta.
    • 2022-10-07 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Right bundle branch block
      • Abnormal ECG
    • 2022-06-27 KUB
      • suspected osteolytic lesions at left iliac and sacral bone
      • No abnormal calcification
      • Unremarkable psoas shadows
      • Suggest clinical correlation and follow up evaluation

[assessment]

  • A higher overshoot of bilirubin total than bilirubin direct might hint a sign that the patient’s red blood cells are breaking down at an unusual high rate.

    • 2023-01-04 Bilirubin total 1.57 mg/dL
    • 2023-01-02 Bilirubin total 1.18 mg/dL
    • 2022-12-30 Bilirubin total 1.06 mg/dL
    • 2022-12-29 Bilirubin total 0.54 mg/dL
    • 2023-01-04 Bilirubin direct 0.31 mg/dL
    • 2022-12-30 Bilirubin direct 0.24 mg/dL
  • During the first half hour of 14 o’clock 2023-01-04, there was a brief tachycardia moment with SBP exceeding 200mmHg. The vital signs are relatively stable now.

  • According to the Concor (bisoprolol 5mg/tab) package insert, the drug shold be swallowed with some liquid and not to be chewed. We are in the process of consulting the distributor for a response.

  • Atenolol can be used as an alternative antihypertensive agent (atenolol 50mg ~ bisoprolol 5mg) available under the brand name Urosin in the stock.

701449858

230104

  • diagnosis - 20230103 admission note
    • Enteropathy-type (intestinal) T-cell lymphoma
    • Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
    • Infection following a procedure, initial encounter
    • Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
    • Pleural effusion, not elsewhere classified
  • past history
    • Deny to have history of cancer, hypertension, mental diseases, asthma or diabetes. 
    • Allergy: NKDA
  • family history
    • Mother: breast cancer.
  • exam findings
    • 2022-12-05 CT - abdomen
      • Indication: Enteropathy-type (intestinal) T-cell lymphoma
      • Abdominal CT with and without enhancement revealed:
        • Abdomen
          • Dilated small intestines at RLQ is found about 6.05cm in largest dimension. Suggest follow up.
          • The urinary bladder is well distended without soft tissue lesion.
          • There is no evidence of destructive bone lesion.
          • Increased intestinal gas is found.
          • The GB is well distended without soft tissue lesion
          • There is no evidence of paraarotic LAPs.
          • Loculated effusion at right anterior abdominal wall is found.
        • Visible chest
          • S/p port-A placement with its tip at Superior vena cava.
          • Small lymph nodes at right sternum, right paracaval and hilar region is found.
      • Imp:
        • Post op. change of the abdomen with loculated effusion at RLQ. Abscess?
        • Mediastinal and sternal lymph nodes, please correlate with PET.
    • 2022-12-02 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy
        • No evidence of T cell prloliferation
        • Hypercellularity (80~90%), in favor of reactive hyperplasia of myeloid linegae
      • Correlation with peripheral blood test, blood smear, flow cytometry and clinical findings is recommended.
      • Microscopically, it shows hypercellularity (80~90%), presence of trilineage marrowe component with increased myeloid lineage. Occasional megakaryocytes are seen. T-cells are highlighted by CD3 and there is no evidence of T cell prloliferation. CD34 and CD117 are negative for blasts.
      • Immunohistochemical stain reveals MPO (diffuse +), CD71(focal+), CD56(-), CD20(focal+), CD138(-), CD10(-) and TdT(-).
    • 2022-11-29 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (115 - 33) / 115 = 71.30%
        • LVEF (%) = 71
        • M-mode (Teichholz) = 71
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; impaired LV relaxation.
      • Normal RV systolic function.
      • Mild MR; mild TR; mild PR.
    • 2022-11-14 CXR
      • Solitary pulmonary nodule at RLL.
      • Interstitial pattern at bil. lower lungs.
    • 2022-10-24 Whole body PET scan
      • Increased FDG uptake in the abdomen and pelvis, right mediastinal lymph nodes, and right infraclavicular fossa lymph nodes, highly suspected T-cell lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      • Glucose hypermetabolic lesions in the right lobe of the liver, highly suspected lymphoma with liver involvement.
      • Increased FDG uptake in bilateral pulmonry hilar regions, probably reactive nodes.
      • Increased FDG uptake in bilateral femoral shaft, the nature is to be determined (lymphoma, severe anemia or other nature ?), suggesting biopsy for further investigation.
      • T-cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2022-10-14 Patho - small intestine resection for tumor
      • Diagnosis:
        • Small intestine, resection — Monomorphic epitheliotropic intestinal T-cell lymphoma (type II enteropathy-associated T-cell lymphoma)
        • Peritoneum, peritonectomy — Monomorphic epitheliotropic intestinal T-cell lymphoma, by direct invasion
      • Gross description
        • Specimen submitted in fresh consists of a segment of small intestine, measuring 54 cm in length, with a piece of peritoneum, measuring 7.8 x 6.5 cm. An invasive tumor measuring 15.0 x 9.5 x 8.0 cm is seen in the central portion and measuring 15.0 and 10.0 cm away from the bilateral resection margins. On cutting, the tumor is gray, solid, elastic. Transmural invasion to mesentery and peritoneum, adhesion, and fistula formation are noted. Several enlraged lymph nodes are found and dissected. Representative sections are taken and labeled as: FsA1-2, for frozen examnation. After formalin fixation, additional sections are taken and labeled as: A1-2: bilateral resection margins; A3-4: with peritoneum; A5-8: tumor (A7: fistula); A9-10: lymph nodes.
      • Microscopic description
        • Sections show small intestine with diffuse, transmural invasion of medium-sized lymphoid cells.
        • Lymph node is involved. The tumor has invaded to the peritoneum and very close (< 0.1 cm) to the resection margin of peritoneum. The bilateral resection margins are free of tumor.
        • The immunohistochemical stains reveal CK(-), CD3(+), CD20(-), CD5(-), CD56(+), CD8(+), CD4(-), and Granzyme B(-).
        • NOTE: The tissue is the same as F2022-477.
    • 2022-10-13 Frozen resection
      • Preliminary diagnosis:
        • Small intestine, biopsy — small round blue cell tumor
    • 2022-10-12 Pulmonary Flow Volume Loop
      • mild restrictive impairment
    • 2022-09-05 Patho - lung transbronchial biopsy
      • Lung, RML, CT-guide biopsy — a tiny cluster of atypical cell present (please see microdescription)
      • Sections show alveolar lung tisssue with a tiny cluster of atypical cells.
      • The atypical cells are not found in deeper section. Please correlate with the clinical presentation.
      • The immunohistochemical stains reveal CK(+), TTF-1(-), p40(-), CD56(-), CDX2(-) and CD117(-).
    • 2022-09-02 CT - chest
      • Indication: Suspected of small bowel malignancy
      • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Subpleural round nodular lesion at right middle lobe up to 0.5cm is found.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Swelling of intestinal wall at RLQ is found. suspected small bowel cancer.
          • Low density change at left liver tip up to 2.8cm is found. Hemangioma is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
        • Imp:
          • Small bowel cancer with right middle lobe meta.
          • Hepatic hemangioma.
    • 2022-09-01 CT - abdomen
      • History and indication: abdominal pain
      • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
      • With and without-contrast CT of abdomen-pelvis revealed:
        • Wall thickening of small bowel with adjacent fat stranding, adjacent bowel loop/ right abdominal wall invasion and LNs metastases.
        • Minimal ascites.
        • Left liver hemangioma (3.3cm).
        • Bil. renal cysts (up to 2.1cm).
        • A nodule (1.3cm) at left adrenal gland.
        • A nodule (6mm) at RML.
        • Normal appearance of spleen, pancreas.
        • Normal appearance of gallbladder.
        • Patency of portal vein.
        • Intact bony structures.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • Atherosclerosis of aorta, iliac arteries.
        • Some calcifications in prostate.
      • IMP:
        • In favor of small bowel cancer with adjacent fat stranding, adjacent bowel loop/ right abdominal wall invasion, LNs and lung metastases.
  • consultation
    • 2022-09-01 General and Gastrointestinal Surgery
      • A
        • S
          • periumbilical pain for one week
          • firm but ill-defined mass over central abdominal area
          • poor appetite for several weeks
          • but no significant BW loss
          • no N/V
          • no tarry/bloody stool
        • PE
          • fair looking
          • pale conjunctive
          • smooth respiration
          • RHB
          • abdomen: soft and distended, but firm mass at central abdomen, no peritoneal sign
        • Lab
          • no leukocytosis, no left shift
          • Hb: 10
          • high CRP
        • CT
          • focal bowel wall thickening wtih fat stranding and peritoneal invasion, favor malignancy, less likely inflammation related
        • suggest
          • admit for preop survey
          • BT with PRBC 2u
          • check tumor markers, HBV and HCV
          • arrange lung CT after admission
  • surgical operation
    • 2022-10-13
      • Surgery
        • small bowel tumor resection
        • peritonectomy
        • partial T-colon colectomy
      • Finding
        • huge tumor over proximal ileum, about 110cm proximal to the ileocacal valve
        • tumor invasion to the abdomianl wall and T-colon
        • multiple enlarged LNs over mesentary
        • no other palpable seeding tumor
        • no ascites
        • frozen section of small intestine: favor lymphoma, less likely adenocarcinoma
  • chemoimmunotherapy
    • 2023-01-03 - methylprednisolone 500mg/m2 900mg D1-4 + etoposide 40mg/m2 70mg 1hr D1-4 + cisplatin 20mg/m2 35mg 18hr D1-4 + cytarabine 1500mg/m2 2700mg 2hr D5 (ESHAP)
      • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + granisetron 2mg D1-5
    • 2022-11-29 - methylprednisolone 500mg/m2 900mg D1-4 + etoposide 40mg/m2 70mg 1hr D1-4 + cisplatin 20mg/m2 35mg 18hr D1-4 + cytarabine 1500mg/m2 2700mg 2hr D5 (ESHAP)
      • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5
  • Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (2023-01-04 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)
    • R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: Martín A, Conde E, Arnan M, et al. R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
      • Administration - R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
      • Adverse effects - Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
      • Outcomes - A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

700552812

230102

  • exam findings
    • 2022-12-30 SONO - abdomen
      • Few small gallstone are noted.
    • 2022-12-09 Nasopharyngoscopy
      • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb post of operation on 2022/02. recurrence malignancy
      • tumor over right part of mouth floor, submandibular space and overlying skin, buccogingival mucosa, medial pterygoid muscle, soft palate, tongue base and oropharyngeal wall, cT4aN3bM0 under palliative chemotherapy
    • 2022-11-12 Nasopharyngoscopy
      • Scope: smooth NPx
      • NG in serted smoothly
    • 2022-10-31 Patho - soft tissue biopsy / simple excision (non lipoma)
      • Labeled as “midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus”, CT guided biopsy — bland spindle cell lesion.
      • IHC stains: desmin (+), CD34(+), Ki-67 <1%. CK(-), CD117(-), Dog-1(-), S-100(-), GFAP(-).
      • The possibility of bland smooth muscle tumor or glomus tumor cannot be excluded. Further work up, including excisional biopsy, might be considered.
    • 2022-10-26 CT - abdomen
      • History and Indication: biliary hepatitis and GI bleeding,
      • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is a poor enhancing lesion measuring 3.4 x 2.2 x 8 cm (width x depth x cranial-caudal length) at the midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus. Please correlate with MRI.
        • Few enlarged nodes in ppara-aortic space are suspected.
        • There is mild ascites in the pelvis.
        • The gallbladder shows few small stones and borderline distension but no wall thickening or surrounding fatty stranding. please correlate with clinical condition.
        • There is a tiny renal stone in right lower pole.
        • S/P nasogastric tube insertion
        • Others
          • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery.
      • Impression:
        • There is a poor enhancing lesion measuring 3.4 x 2.2 x 8 cm (width x depth x cranial-caudal length) at the midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus. Please correlate with MRI.
          • The differential diagnosis include urachal cyst with infection, urachal tumor, and uterine tumor?
        • Few enlarged nodes in ppara-aortic space are suspected.
        • There is mild ascites in the pelvis.
    • 2022-10-25 SONO - abdomen
      • GB stone, multiple
      • GB sludge
    • 2022-10-24 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Duodenal ulcers with stigma of recent hemorrhage, Forrest classification type IIa or IIc, bulb and 2nd portion s/p
        • hemostasis with APC
        • Gastric ulcer scar, prepyloric antrum, LC site
        • Hypopharynx mass lesion
        • Reflux esophagitis LA grade A
        • Superficial gastritis, s/p CLO tes
        • Gastric erosions, middle body, GC site
      • Suggestion
        • Keep on IV PPI therapy
        • F/U CLO test
    • 2022-10-23 ECG
      • sinus rhythm
      • Left axis deviation
      • Low voltage QRS
    • 2022-10-23 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • S/P port-A catheter insertion.
      • S/P N-G tube insertion.
    • 2022-10-23 Supine KUB
      • Presence of pneumatosis intestinalis over right-side of the abdomen.
      • S/P N-G tube insertion.
    • 2022-10-09, -09-27 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • Increased infiltration over LLL. May be active infection.
      • Degenerative joint disease of T-spine with marginal osteophytes.
      • S/P port-A catheter insertion.
    • 2022-09-08 MRI - nasopharynx
      • Post-OP follow up. Pain of right neck and face. Recent fever was noted.
        • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb s/p wide excision; neck dissection and free flap reconstruction
        • Complete CCRT
        • Scar contraction of right neck
        • Painful swelling of left neck
        • A fixed palpable mass was noted of right submandibular region with skin involved; Highly suspected tumor recurrence
      • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1WI with FS (thickness=5 mm, gap=1mm) and sagittal T1WI with FS(thickness= 4 mm, gap=1 mm) and show:
        • Extensive soft tissue mass with heterogeneous enhancement involving right part of mouth floor, submandibular space and overlying skin, buccogingival mucosa, medial pterygoid muscle, soft palate, tongue base and oropharyngeal wall (with necrotic change). Abnormal intensity also noted in right mandible, masseter muscl, along sternocleidomastoid muscle and surrounding right proximal ECA.
        • S/P flap reconstrution of right part of the oral tongue and lymph node dissection at right neck.
        • No enlarged lymph node.
        • No abnormality at nasopharynx, hypopharynx and larynx.
      • IMP:
        • Right tongue border cancer s/p treatment with advanced recurrence is first considered.
    • 2022-08-19 CT - abdomen
      • History:
        • Persistent cholestatic hepatitis of unexplained cause.
        • Recent echo showed no biliary lesion
      • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Impression:
        • Few gallstones are noted and the size < 5 mm.
        • A small renal stone 3 mm in right lower pole is noted.
    • 2022-08-15 SONO - nephrology
      • Parenchymal renal disease
      • Incomplete voiding, mild
    • 2022-08-10 SONO - abdomen
      • Parenchymal liver disease
      • GB stones (non-fasting GB)
    • 2022-07-07 Stomach, antrum, biopsy— ulcer with Helicobacter infection
    • 2022-07-06 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Duodenal ulcer, Forrest classification type IIa, bulb s/p hemostasis with APC
        • Reflux esophagitis LA grade A
        • Superficial gastritis
        • Gastric ulcer, Forrest classification type III, antrum
        • Duodenal ulcer, Forrest classification type III, D1 to D2
      • Suggestion
        • High dose PPI *3 day
        • F/U patho
    • 2022-06-08 MRI - nasopharynx
      • Post-OP follow up
        • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb s/p wide excision; neck dissection and free flap reconstruction
        • Complete CCRT
      • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1-WI (thickness=5 mm, gap=1mm) and sagittal T1WI (thickness= 4 mm, gap=1 mm) and showed:
        • post-OP change at the right tongue with neck dissection and free flap reconstruction.
        • heterogeneous enhancing lesions in the right oropharynx, right buccogingival mucosa and right tongue base.
      • IMP:
        • suspected tumor recurrence in the heterogeneous enhancing lesions in the right oropharynx, right buccogingival mucosa and right tongue base.
    • 2022-02-07 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Duodenal ulcer with suspicious SRH, Forrest class IIa, SDA, s/p APC
        • Duodenal ulcers with oozing bleeding, Forrest Ib, second portion, s/p APC
        • Gastric ulcers
        • Reflux esophagitis LA grade A
        • Superficial gastritis, s/p CLO test
        • Incomplete study due to retention of food residue
      • Suggestion
        • High dose PPI use
        • Pursue CLO test result
        • Suggest second-look endoscopy in 2-3 days.
    • 2022-02-07 Sigmoidoscopy
      • Diagnosis
        • Tarry-bloody colon content, suggestive of bleeding proximal to the distal colon
        • Internal hemorrhoids
        • Incomplete study of colon
      • Suggestion
        • This finding is compatible with the clinical diagnosis of UGI bleeding
        • Correlate with other clinical information
        • Repeat colonoscopy after full bowel preparation if clinically indicated
    • 2022-02-07 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • GB stones
        • CHD dilatation, mild; CBD masked
        • Parenchymal renal disease
        • Minimal amount of right pleural effusion with subpleural consolidation of right lower lung
        • suboptimal echo window
      • Suggestion
        • OPD follow-up
    • 2022-02-05 CT - abdomen
      • Gallbladder stones
      • Right renal stone
      • Intravenous contrast leakage in this study
    • 2022-01-25 Pathology - oral cancer (wide excision + lymph node)
      • Diagnosis
        • Tongue, right, frozen section for base margin (F2022-30) followed by wide excision S2022-1491) — Squamous cell carcinoma, well differemtiated
        • Frozen section for base margin (F2022-30) — Free.
        • Lymph node, right neck, dissection — Metastatic carcinoma
          • pT4a pN3b (if cM0) and if p16 is negative; pStage: IVB, at least.
        • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.”, “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • Macroscopic examination
        • Surgical Procedure(s): wide excision and radical neck lymph node dissection
        • Specimen Type:
          • Main location: right tongue
          • Other part(s) included: right mandibular gland
          • Lymph node dissection: yes right radical neck dissection
        • Specimen Integrity: intact
        • Specimen Size: Greatest dimensions: Tissue labeled as “01. Main tumor, right”: 7 x 5.5 x 3.5 cm.
          • Additional dimensions (if more than one part): Tissue labeled as “02. right mandibular gland”: 5 x 3.6 x 2.5 cm. And Frozen section tissue (F2022-30) labeled as “base, right”: 1 piee: 0.6 x 0.4 x 0.3 cm.
        • Depth of invasion: 17 mm
        • Tumor Site: right tongue border
          • Laterality: right
        • Tumor Focality: single focus
        • Tumor Size: Greatest dimension: 4.7 cm
          • Additional dimensions (if available): 2.2 x 1.7 cm
        • Mucosal Surface: ulcerated
        • Gross Tumor Extension: muscle
        • Tissue for frozen section: F2022-30: right base margin.
        • Tissue for formalin fixation: S2022-1491A: right main tumor= A1: vertical section of tumor with superior or ventral side margin; A2: vertical section of inferior or mouth floor side margin A3: vertical section of tumor with anterior margin; A4: vertical section of posterior margin; A5: gingiva; A6-9: tumor; A10: sublingual gland; B1: level 1 lymph node; B2-3: level 2 lymph nodes (with the largest one bi-sected, submitted in B2); B4-6: level 3 lymph nodes ( the larger two lymph nodes bi-seted and submitted in B4 and B5); B7: level4 lymph nodes; B8-9: level 5 lymph nodes (with the larger one bi-sected, submitted in B8); B10-11: parotid tail lymph nodes; B12-16: submandibular gland; B17: submandibular gland lymph nodes.
      • Microscopic examination
        • Histologic Type: Squamous cell carcinoma, (classical variant)
        • Histologic Grade: G2: Moderately differentiated
        • Microscopic Tumor Extension: (specify) muscle
        • Margins- Margins uninvolved / involved by invasive carcinoma
          • Distance from closest margin: 7 mm from base margin of the main tissue. This distance does not included the size of the frozen section specimen.
        • Margins uninvolved / involved by moderate and/or severe dysplasia: no dysplasia
          • Distance from closest margin: Not applicable
        • Lymph-Vascular Invasion: present
        • Perineural Invasion: present
        • Neck Lymph Nodes:=B1: level 1 lymph node (0/2); B2-3: level 2 lymph nodes (1/7, 2 mm in size, with extranodal extension); B4-6: level 3 lymph nodes ( 3/12, largest focus 21 mm, with ENE); B7: level4 lymph nodes (0/3); B8-9: level 5 lymph nodes (0/8); B10-11: parotid tail lymph nodes(0/14); B12-16: submandibular gland (0/3); B17: submandibular gland lymph nodes (0/3).
          • Ipsilateral: Number examined: 52; Number involved: 4
          • Contralateral (if available): N/A
        • Size (greatest dimension) of largest metastatic deposit: 2.1 cm
        • Extranodal extension: present
        • IHC stain: p16 (-).
    • 2022-01-21 Tc-00m MDP whole body bone scan
      • Increased activity in the lower C-spine and L3-4 spines. Degenerative change may show this picture.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
    • 2022-01-20 MRI - Nasopharynx
      • Indication: SCC of right tongue border
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Findings
        • Right lateral tongue tumor, up to 43 mm in length and 18 mm in depth.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • Multiple enlarged right level I-II LNs, some with central necrosis.
      • IMP:
        • Right tongue CA, with neck LAPs. T3N2bMx Stage IVA
    • 2022-01-05 Patho - tongue biopsy
      • Labeled as “right tongue border”, incision biopsy — squamous cell carcinoma.
      • IHC stains: p40 (+), p16 (-).
    • 2020-11-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (156 - 64) / 156 = 58.97%
        • M-mode (Teichholz) = 59
      • Gr II LV diastolic dysfunction; severely dilated LA and dilated RA.
      • Dilated LV with normal LV and RV systolic function.
      • Prominent posterior mitral annulus calcification with trivial MR; trivial TR; mild aortic valve sclerosis.
      • Prominent aortic root calcification with multiple large protruding atheromas (1.2-1.7 cm of thickness).
      • Dilated proximal ascending aorta (34mm).
  • chemotherapy
    • 2022-12-27 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-12-13 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-11-29 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-11-15 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-09-30 - docetaxel 40mg/m2 50mg 2hr + carboplatin AUC 2 150mg 3hr + (leucovorin 100mg/m2 130mg + fluorouracil 1000mg/m2 1300mg) 22hr
      •                 diphenhydramine 30mg + granisetron 1mg
    • 2022-09-29 - cetuximab 400mg/m2 500mg 2hr
      •                 diphenhydramine 30mg
    • 2022-09-13 - decetaxel 40mg/m2 50mg 2hr + carboplatin AUC 2 150mg 3hr + (leucovorin 100mg/m2 130mg + fluorouracil 1000mg/m2 1300mg) 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-04-25 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2022-04-15 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-04-06 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-03-23 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-03-15 - carboplatin AUC 2 150mg 3hr
      •                 diphenhydramine 30mg + granisetron 1mg

[assessment]

  • 2023-01-01 lab results indicated serum K, Na, Mg and albumin were below normal ranges, and an adequate corresponding supplement may be beneficial.

701454820

230102

  • diagnosis - 2022-11-19 discharge note
    • Pancreatic tail cancer with liver metastasis, stage IV s/p chemotherapy with FOLFIRINOX from 2022/10/21
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
  • past history
    • Hypertension in 2021/10 with Norvasc 1# po QD and Carvedilol 6.25mg 1# po QD control
    • Hyperlipidemia in 2021/10 with Crestor 10mg 1# po QD control          
  • family history
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.   
  • lab data
    • 2022-10-07 Anti-HBc Nonreactive
    • 2022-10-07 Anti-HBc-Value 0.15 S/CO
    • 2022-10-07 Anti-HBs 163.89 mIU/mL
    • 2022-10-07 HBsAg (quantitative) Nonreactive
    • 2022-10-07 HBsAg Value (quantitative) 0.00 IU/mL
    • 2022-10-07 Anti-HCV Nonreactive
    • 2022-10-07 Anti-HCV Value 0.07 S/CO
    • 2022-09-26 CA-199 22806 U/mL (Taipei Mackey Hospital)
  • exam findings
    • 2022-11-05 ECG
      • Normal sinus rhythm
      • Incomplete right bundle branch block
      • ST elevation, consider early repolarization, pericarditis, or injury
      • Abnormal ECG
    • 2022-10-11 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Adenocarcinoma, well differentiated, compatible with metastatic pancreatic ductal adenocarcinoma
      • The sections show a picture of adenocarcinoma, well differentiated, composed of nests of columnar neoplastic cells with slightly pleomorphic nuclei, abundant cytoplasm, mucin secretion, and form duct-like glandular structures, mainly in portal areas. Vascular invasion is present.
      • IHC shows: CK7(+), CK20(+), and CA19-9(+). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
    • 2022-09-19 MRI (TaiAn Hospital)
      • Suspected pancreatic tumor (4 cm) with adhesion to spleen hilum, tail and suspected liver metastasis.
  • chemoimmunotherapy (FOLFIRINOX)
    • 2022-12-30 - oxaliplatin 85mg/m2 150mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4200mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-12-16 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-29 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-16 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-02 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3

==========

2022-11-30

  • With an initiating of dose-reduced irinotecan and skipped fluorouracil bolus, FOLFIRINOX has been administered to this patient with pancreatic tail cancer with liver metastases since 2022-10-21, and no serious adverse reactions have been reported.
  • In recent lab tests, CEA (2022-11-15 20.18ng/mL) and CA199 (2022-11-15 >19090U/mL) levels remained high.
  • The underlying conditions of hypertension and hyperlipidemia are managed with patient-carried medication with no extreme abnormal results on examinations.

701012983

221229

  • diagnosis
    • Malignant neoplasm of duodenum
  • past history]
    • Past medical history:
      • Cardiovascular disease - CAD, DM
      • Hepatitis B or C carrier - denied
      • Current medications – DAPT
    • Past surgical history:
      • no gastrectomy/colectomy/splenectomy   
  • family history]
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.     
  • exam findings
    • 2022-11-08 CT - abdomen
      • Clinical history: 56 y/o male patient with duodenal adenocarcinoam pT3bN2 cM0; stage IIIB, s/p Op in May 2022.
      • With and without contrast enhancement CT of abdomen whole:
        • S/P whipple operation.
        • Right renal cyst, 1.2cm.
        • Unremarkable change of the liver, spleen and left kidney.
        • There are multiple enlarged lymph nodes in the paraaortic, aortocaval and peripancreatic regions.
        • Presence of ascites.
      • Impression:
        • S/P whipple operation.
        • Multiple metastatic lymph nodes and ascites, progression.
        • R/O right renal cyst.
    • 2022-11-08 CXR
      • Spondylosis of the T-spine
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-11-01 SONO - abdomen
      • Diagnosis
        • Dilated CBD
        • Dilated left intrahepatic duct
        • Splenomegaly, mild
        • Ascites
        • Pancreas masked
      • Suggestion
        • No more fever
        • elevated CEA/CA 19-9
        • highly suspected tumor reucrrent
        • Suggest medical ONC follow up and treat, but patient refuse (due to no money). suggest him seeking help from social worker but also refuse.
    • 2022-06-13 CXR
      • Ground glass opacity in bilateral lower lungs.
    • 2022-06-08 CXR
      • Ground glass opacity in RLL.
    • 2022-05-31 Patho - pancreas total/subtotal resection
      • Pathologic diagnosis
        • Duodenum, 2nd and 3rd portion, whpple operation — Periampullary adenocarcinoma, poorly differentiated
        • Pancreas, head, whpple operation — Involved by adenocarcinoma
        • Lymph node, peripancreatic, dissection — Metastatic adenocarcinoma (2/2)
        • Lymph node, group 7,8,9, dissection — Metastatic adenocarcinoma (2/3)
        • Gallbladder, whpple operation — Negative for malignancy
        • Omentum, whpple operation — Negative for malignancy
        • AJCC 8th edition Pathology stage: pT3bN2(if cM0); AJCC stage IIIB
    • 2022-05-24 CT - chest
      • History: Duodenal cancer
      • Impression
        • no abnormality in both lungs. 2nd portion duodenal tumor with pancreatic head involvement and complete obstruction.
        • suspect old subendocardial infarct in LAD territory.
    • 2022-05-19 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 33) / 109 = 69.72%
        • M-mode (Teichholz) = 68
      • Adequate LV systolic function with normal resting wall motion
      • Dilated aortic root
      • Septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Trivial MR and trivial TR
      • Preserved RV systolic function
    • 2022-05-18 Pulmonary Flow Volume Loop
      • Mild restrictive lung defect
    • 2022-05-17 MRI - pancreas
      • History and indication: Duodenal stricture
      • Findings
        • Marked motion artifact.
        • Wall thickening of duodenum, 2nd portion, with pancreas invasion. Some LNs at retroperitoneum.
        • Distention of stomach.
        • Tiny renal cysts.
        • Normal appearance of liver, spleen, adrenals.
        • Normal appearance of gallbladder.
        • Patency of portal vein.
        • No ascites.
        • No abnormal intensity in bilateral basal lungs.
      • IMP:
        • In favor of duodenal tumor with pancreas invasion and obstruction.
    • 2022-05-17 Patho - stomach
      • Labeled as “Some white and plaque-like lesions were noted at lower esophagus”, biopsy (B) — ulcer. PAS stain shows no fungal species.
    • 2022-05-17 Patho - stomach
      • Duodenum, SDA, s/p biopsy (A) — adenocarcinoma.
      • IHC stain: Her2/neu: negative (score =0)
      • Section shows duodenal mucosal tissue with irregular aborted glands and isolated signet ring-like neoplastic cells.
    • 2022-05-16 Upper GI and Small Intestine
      • UGI and small bowel series revealed:
        • The contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
        • Normal contour and mucosal pattern of the esophagus.
        • Distention of stomach.
        • Normal appearance of duodenal bulb.
        • Partial obstruction of duodenum (2nd portion).
        • No abnormal bowel loop displacement.
        • The passage time is about 120 minutes.
    • 2022-05-16 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade D
        • Suspected esophageal candidiasis, lower esophagus, s/p biopsy (B)
        • Superficial gastritis
        • Duodenal obstruction, SDA, r/o peptic stricture according to the recent endoscopic diagnosis of duodenal ulcers in other hospital, s/p biopsy (A)
        • Incomplete study due to residual food retention
      • Suggestion
        • Consult GS for surgical evaluation
        • Arrange upper GI series
    • 2022-05-13 CT - abdomen
      • History: vomit with coffee ground for days accompanied with tarry stool for once since this morning. Abdominal distended
      • Indication: GI bleeding.
      • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is asymmetrical wall thickening at the duodenal 2nd portion, causing marked distension of the stomach S/P nasogastric tube insertion.
          • Please correlate with gastroscopy to R/O ulcer with deformity or cancer?
        • There is a poor enhancing lesion in the pancreatic uncinate process, measuring 1.5 cm in size.
          • Please correlate with CA199 and MRI.
        • A renal cyst measuring 1.5 cm in right upper pole is noted.
        • There is no focal abnormality in the liver, gallbladder, biliary system, spleen & left kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • There is asymmetrical wall thickening at the duodenal 2nd portion, causing obstruction.
          • Please correlate with gastroscopy to R/O ulcer with deformity or cancer?
        • There is a poor enhancing lesion in the pancreatic uncinate process, measuring 1.5 cm in size.
          • Please correlate with CA199 and MRI.
    • 2022-05-13 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Suboptimal study due to much residual food retention
        • Reflux esophagitis LA Classification grade C
        • Superficial gastritis
        • Suspicious of duodenal ileus
      • Suggestion
        • Suggest NG tube decompression use
        • Arrange KUB

[assessment]

  • The patient has been diagnosed with duodenal cancer for several months. There may be a reason why he does not actively participate in treatment because he is financially underprivileged (according to social service team’s note 2022-12-28). The availability of treatment options may be limited as a result.
  • With adequate hydration and flomoxef treatment, the decreased blood pressure has returned to normal (95/55 to 127/70) on 2022-12-29.

700022077

221228

  • exam findings
    • 2022-12-03 CT - abdomen
      • Findings:
        • Wall thickening of cecum and proximal A-colon with adjacent mesentery and peritoneal invasions.
        • Multiple enlarged regional lymph nodes, more than 10.
        • Multiple mass lesions with peripheral enhancement in liver.
        • No ascites or extraluminal free air.
        • Enlarged lymph nodes in para-aortic region.
        • No bony destructive lesion on these images.
        • Multiple nodular lesions in both lung fields.
      • Impression
        • suspected Acending colon CA with peritoneal invaion, lymph node metastasis, and liver & lung metastasis

==========

2022-12-28

  • A nasogastric tube can be used to administer all of the oral medications listed in the active prescription.
  • There may be an enhanced CNS depressant effect when tramadol, chlorzoxazone, and oxazolam are administered together.
  • Amlodipine and tramadol’s serum concentrations may be increased by fluconazole, a moderate CYP3A4 inhibitor.
  • The ingredients in Acetal, Sketa, and Tramacet all include acetaminophen. The maximum daily dose of acetaminophen is not recommended to exceed 3000mg.
  • Please continue to monitor any potential adverse reactions caused by drug interactions.

2022-12-05

  • The CT image taken on 2022-12-03 indicated that cancer of the colon or cecum may be present. A work-up is currently being conducted on the patient. As far as the active prescription is concerned, there is no problem.

701173809

221228

  • diagnosis
    • Sigmoid cancer with obstruction and invasion to cecum s/p Colostomy then Sigmoid colectomy with lymph nodes dissection and Right hemicolectomy on 2019/03/23, pT4bN2bM0, stage IIIC s/p adjuvant chemotehrapy with FOLFOX for 6 cycles with tumor seeding with posterior lateral aspect
    • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
    • Chronic viral hepatitis B without delta-agent
  • past history
    • GERD history 20+ years ago;
    • Lumbar spondylolisthesis, L2-L3 post medical treatment in hospitalized 20+ years ago;
    • Sigmoid colon cancer with obstruction, pT4bN2bM0, stage IIIC s/p T-loop colostomy on 2019/03/23; s/p sigmoid colectomy and right hemicolectomy on 2019/03/27; s/p post Port A catheterimplatation on 2019/04/03. mFOLFOX-6 adjuvant chemotherapy x 6 times then shifted to high dose 5-FU x 6 times on 2019/07/08 to 2019/09/18.
    • Left Kidney clear cell renal carcinoma , pT1aN0M0 s/p partial nephrectomy on 2019/12/31
  • exam finding
    • 2022-09-30 CT - abdomen
      • History:
        • 20190323 CT: sigmoid colon cancer with total obstruction.
        • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy. Patho: pT4bN2bM0, pstage IIIC
        • 20191231 S/P partial Lt nephrectomy:RCC, clear cell, pT1aN0M0
        • 20220413 CT: a lesion in Lt 11th rib intercostal space, Suspected meta.
        • 20220502 CT-guided biopsy patho favor metastasis c/w colon origin. a lesion in Lt kidney middle pole, suspected recurrent RCC? clinician favor old hematoma.
      • Findings:
        • S/P partial nephrectomy at left kidney upper pole.
          • Prior CT identified a poor enhancing lesion 1.6 x 1.3 cm in left kidney middle pole is noted again, mild decreasing in size to 1.2 x 0.7 cm. Follow up is indicated.
          • Prior CT identified a metastasis measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib intercostal space is not noted again in the current CT that is c/w metastasis S/P surgical resection.
        • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
        • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
      • Impression:
        • S/P partial nephrectomy at left kidney upper pole.
        • There is no evidence of tumor recurrence.
    • 2022-05-27 Patho - peritoneum biopsy
      • Diaphragm, left, excision — Metastatic adenocarcinoma, consistent with colorectal origin
      • Sections show fibroadipose and skeletal muscular tissue with invasive neoplastic glandular cells.
      • The immunohistochemical stain of CDX2 is positive. Lymphovascular invasion is found. The result and morphology are consistent with metastatic adenocarcinoma from colorectal origin. The peripheral resection margins are free of tumor. The tumor is very close (<0.1cm) to the serosal surface.
    • 2022-05-26 CXR
      • Thoracic aortic arch calcified atheriosclerotic plaque
    • 2022-05-19 Whole body PET scan
      • Glucose hypermetabolism in a focal area in the posterior lateral aspect of left 11th-12th intercostal space, in a focal area in the posterior aspect of left kidney, in a focal area in the middle lower pelvis just in the left anterolateral aspect of rectum and in a focal area in the right anterior lower pelvis. Multiple metastatic lesions should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • A glucose hypermetabolic lesion in the middle pole of left kidney. Recurrent malignancy should be watched out. Please also correlate with other clinical findings for further evaluation.
    • 2022-05-03 Patho - soft tissue nontumor/mass/lipoma/debridement
      • Labeled as “left 11 rib”, (clinically: sigmoid colon cancer and renal cell cancer), CT guided biopsy — metastatic adenocarcinoma.
      • IHC stains:
        • CD10 (-) and RCC (-): dis-favor RCC,
        • CK20 (+): compatible with colon origin;
        • TTF-1 (-): dis-favor pulmonary origin;
        • PSA (-): dis-favor prostatic origin.
      • Section shows soft tissue with many small nests of criform pattern adenocarcinoma.
    • 2022-04-13 CT - abdomen
      • History:
        • 20190323 CT:sigmoid colon cancer with total obstruction.
        • 20190327 surgery: Sigmoid cancer with obstruction and invasion to the cecum s/p Sigmoid colectomy + Right hemicolectomy
          • Patho: pT4bN2bM0, pstage IIIC
        • 20191231 S/P partial Lt nephrectomy: RCC, clear cell, pT1aN0M0
      • Findings
        • S/P partial nephrectomy at left kidney upper pole.
          • Prior CT identified a poor enhancing lesion 0.9 cm in left kidney middle pole is noted again, mild increasing in size to 1.6 x 1.3 cm.
          • A newly-developed renal cell carcinoma is suspected. Please correlate with contrast enhanced dynamic CT or MRI.
          • In addition, another newly-developed heterogeneous poor enhancing mass measuring 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is noted that may be tumor seeding.
        • Prior CT identified a cyst 7 mm in S4 and a hemangioma 1.3 cm in S7 of the liver are noted again, stationary.
        • S/P right hemicolectomy and S/P LAR with autosuture retention over the sigmoid colon.
      • Impression
        • RCC 1.6 x 1.3 cm in Lt kidney middle pole is suspected.
        • Tumor seeding 2.7 x 1.4 cm in the posterior lateral aspect of left 11th-12th rib rintercostal space is highly suspected. please correlate with clinical condition and biopsy.
    • 2021-12-30 SONO - abdomen
      • Diagnosis
        • Negative finding
        • Pancreas not shown
      • Suggestion
        • OPD f/u
        • Follow liver function test and AFP
        • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
    • 2021-07-01 CT - abdomen
      • S/P colon operation.
      • Small liver cyst and hemangioma.
      • Left renal tumors (0.9cm, 2.7cm) without interval change.
    • 2021-04-01 CT - abdomen
      • S/P colon operation.
      • Small liver cyst and hemangioma.
      • Left renal tumors (0.9cm, 2.7cm).
    • 2020-03-20 CT - abdomen
      • dilated small bowel. suspected small bowel ileus.
      • recent renal infarction in the left kidney.
    • 2020-01-02 Surgical pathology Level V
      • PATHOLOGIC DIAGNOSIS:
        • Kidney, left, partial nephrectomy — Clear cell renal cell carcinoma with sarcomatoid feature
        • Pathology stage: pT1aNx, stage I at least
      • MICROSCOPIC EXAMINATION
        • Histological type: Clear cell renal cell carcinoma
        • Sarcomatoid features: Present (80%)
        • Rhabdoid features: Not identified
        • Histologic grade: Grade 4
        • Tumor necrosis: Present (20%)
        • Tumor Extension: Tumor limited to kidney
        • Margins: Uninvolved by invasive carcinoma
        • Lymphovascular invasion: Not identified
        • Regional lymph nodes (pN): No lymph node found
        • Distant metastasis (pM): Not applicable
        • Nonneoplastic kidney: Chronic pyelonephritis
    • 2019-12-02 MRI - liver, spleen
      • A hemangioma (1.3cm) in S7 of liver. A cyst (0.5cm) in S4 of liver.
      • A poor enhancing tumor (2.7cm) in left kidney suspected hypovascular RCC.
    • 2019-09-26 CT - abdomen
      • Colon cancer s/p operation with colostomy. No evidence of tumor recurrence.
      • A poor enhancing tumor (2.7cm) in left kidney (mild increased size).
      • A poor enhancing tumor (1.1cm) in S7 of liver without interval change.
    • 2019-06-25 CT - abdomen
      • No evidence of recurrent tumor in the study.
    • 2019-03-27 Surgical pathology Level VI
      • PATHOLOGIC DIAGNOSIS
        • Sigmoid colon, colectomy — Adenocarcinoma, moderately differentiated
        • Ascending colon, R’t hemicoloectomy — Adenocarcinoma, compatible with direct tumor invasion from sigmoid cancer
        • Proximal & distal surgical margins — Free of tumor invasion
        • Lymph nodes, mesocolic, dissection — Positive for tumor metastasis (8/43) with extracapsular extension (2/8)
        • Appendix, terminal ileum — Free of tumor invasion
        • AJCC pathologic stage — pT4bN2bMx, stage IIIC at least
      • MICROSCOPIC EXAMINATION
        • Histology: sigmoid adenocarcinoma directly invades to ascending colon
        • Histology Grade: G2: moderately differentiated
        • Depth of invasion: direct invades adjacent colon
        • Angiolymphatic invasion: Present
        • Perineural invasion: NOT identified
        • Discontinuous extramural tumor extension: Not identified.
        • Circumferential (radial) margin of rectosigmoid: Involved
        • Lymph node metastasis, mesocolic: Positive for tumor metastasis (8/43)
        • Lymph node metastasis, IMA / SMA: N/A
        • Extranodal involvement: Present (2/8)
        • Pathological TNM Stage: pT4bN2bMx, stage IIIC at least
        • Type of polyp in which invasive carcinoma arose: N/A
        • Additional pathologic findings: N/A
        • TNM descriptors: N/A
        • Tumor regression grading S/P CCRT: N/A
        • Proximal & distal margins: free from tumor invasion
    • 2019-03-26 Surgical pathology Level IV
      • Colon, sigmoid, 20 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2019-03-23 CT - abdomen
      • Indication: Abdominal dull pain for 2-3 days, mostly over the right, abdominal fullness with no stool passage for 2 days, N∕V(+), no chest pain, no SOB, no flank pain, denied OP history
      • Imaging Report Form for Colorectal Carcinoma
      • Impression:
        • Dilated colon and small intestines with transitional point at sigmoid colon, suspected foreign body related or sigmoid colon cancer.
        • T3N1Mx, IIIB
  • surgical operation
    • 2022-05-27 Excision of chest wall and repair of diaphragmatic defect.
      • One solid nodular lesion was noted over left CP angle, near diaphram and 11th intercostal muscle, size about 3cm in max. diameter.
      • One J-P drain was inserted beneth the wound.
    • 2020-03-23 Enterolysis with bowel decompression
      • Adhesion band and causing small bowel dilatation
    • 2019-12-31 Partial nephrectomy
    • 2019-10-30 Closure of enterostomy or Colostomy (loop or double-barrel)
    • 2019-03-27 Left hemicolectomy or sigmoid colectomy with anastomosis with lymph node
    • 2019-03-23 Enterostomy for suspected S-colon cancer with obstruction
  • drug allergy
    • Eloxatin (oxaliplatin 50 mg/vial) - whole body rash, fever all over
  • chemoimmunotherapy
    • 2022-12-27 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-12-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-11-03 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-10-17 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-09-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-08-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg ST & 4mg BID D1-3 + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-08-02 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 400mg/m2 760mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4500mg 46hr (Avastin + FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + aprepitant 125mg ST & 125mg QD D2-3
    • 2022-06-14 - irinotecan 120mg/m2 225mg 90min + leucovorin 400mg/m2 760mg 2hr + fluorouracil 200mg/m2 380mg 10min + fluorouracil 2400mg/m2 4570mg 46hr (FOLFIRI, Q2WK)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg IVD + granisetron 2mg
    • 2019-07-08 ~ 2019-09-18 - Adjuvant chemotherapy with mFOLFOX6 for 6 times.

==========

2022-12-28

  • The CEA and CA199 markers did not show any obvious trend over the past six months.
  • Lab data for 2022-12-27 showed a WBC level of 3.82K/uL and a neutrophil percentage of 37%. The possibility of potential infectious events and neutropenia might be kept in mind.
  • The most recent CT was dated on 2022-09-30. Possibly, the lesion in the middle pole of the left kidney should be followed up. It may be updated if it is considered to be beneficial to clinical decision-making.
  • The active prescription does not pose a problem.

2022-10-18

The patient’s vital signs, laboratory data (2022-10-11), and the disease are in a generally stable state.

2022-09-28

There is no issue with the active prescription. It is recommended that the last abdomen CT image be updated as it is dated 2022-04-13. A metastatic adenocarcinoma around the left 11th and 12th ribs (2022-05-03 pathology) might be surgically removed if it is symptomatic and feasible.

2022-09-14

There was a generally normal lab result on 2022-09-12 and a relatively stable TPR and BP reading during this hospital stay. With the current regimen, the patient has tolerated it. In this case, the patient has only a muscle power of 4 or less, so some assistive devices might be beneficial.

700132375

221226

{drug identification}

The drug imprinted “CTP A23” on the red-white capsule has not been found in available databases and remains unidentified.

700555339

221226

  • exam findings
    • 2022-11-25 KUB
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
      • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
    • 2022-11-25 Chest supine view
      • Widening of the right upper mediastinum is noted, which may be due to torturous innomiate vessel or tumor. Please correlate with standing p-a view or CT.
      • Borderline cardiomegaly
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-11-25 Chest plain film
      • Unremarkable change in the visible trachea
      • cardiomegaly; mediastinal widening.
      • Lung markings: unremarkable.
      • Normal bilateral hemidiaphrams
      • Clear bilateral costophrenic angles
      • Unremarkable change in bilateral clavicles
    • 2022-06-05 CT - abdomen (at Shin Kong Hospital)
      • Tumor location: U-M/3 rectum
      • Tumor size: Measurable: around 3.5-cm (largest diameter)
      • Tumor invasion: T4b, transmural, right adnexal to right uteirne border.
      • Regional nodal metastasis: N2, five nodes along IMA.
      • Distant metastasis (In this study): No Other findings: small nodes around IMA orifice level of aorta/IVC.
      • Impression :
        • Locally invasive U-M/3 rectal cancer, T4bN2M0 stage with segmental obstructive colitis.
        • Questionable small nodes around IMA orifice level of aorta/IVC.
        • CBD dilatation with sludge.
        • A-colon diverticulae.
        • Uneven fatty liver with S5 cyst.
        • L3-5 spinal stenosis with left L4-5

==========

2022-12-26

[ABX use evaluation]

For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein. Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.

2022-11-28

  • Based on the recent diagnosis and prescription in the PharmaCloud, the patient should have underlying conditions such as CKD stage 3 (N18.3), lumbar region spondylosis with radiculopathy (M4726), cardiovascular promblem (nicorandil, bisoprolol, spironolactone), and diabetes (vildagliptin, gliclazide).
  • Nicorandil and bisoprolol have been added to the active prescription as patient-carried items and regular insulin 2 units BID is being used, both the blood pressure and blood sugar levels are within acceptable ranges.
  • As of 2022-11-28, the eGFR is 72.1, so there is no need to adjust the dosage.
  • The elevated CRP level is decreasing (4.63mg/dL 2022-11-28 <- 13.09ng/dL 2022-11-25), which might suggest a mitigation in the condition.
  • The active prescription does not pose an issue.

700864309

221222

  • exam findings
    • 2022-12-09 SONO - urology
      • Right renal stone
      • Right renal cyst
    • 2022-12-09 Bladder Sonography
      • PVR: 22.8ml (PVR = postvoided residual)
    • 2022-12-09 TRUS-P, Transrectal Ultrasound of Prostate
      • Benign prostatic hyperplasia
    • 2022-11-23 Patho - stomach biopsy
      • Labeled as “30cm below the incisors”, Biopsy (B) — benign hyperplastic squamous mucosa.
      • Stomach, antrum. Biopsy (A) — Chronic gastritis, H pylori present
    • 2022-11-23 Whole body PET scan
      • Glucose hypermetabolic lesions in the left soft palate, compatible with the primary malignant neoplasm of soft palate.
      • Glucose hypermetabolic lesions in bilateral cervical lymph nodes, highly suspected cancer with regional lymph nodes metastases.
      • Glucose hypermetabolic lesions in bilateral pulmonary hilar regions, probably reactive nodes.
      • Malignant neoplasm of soft palate, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
    • 2022-11-22 MRI - nasopharynx
      • Indication: soft palate cancer
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
        • A left soft palate tumor, extending to right, up to 3 cm.
        • Enlarged bil. neck LNs.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor and LNs.
      • IMP:
        • Left soft palate tumor, T2N2M0 stage II (P16+), IVA (P16-).
      • Imaging Report Form for Oropharynx Carcinoma
        • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:II (P16+), IVA(P16-)(Stage_value)
    • 2022-11-22 Esophagogastroduodenoscopy, EGD
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia.
      • Esophageal ulcer, M/3, s/p biopsy (B)
      • Superficial gastritis, s/p CLO test
      • Gastric shallow ulcers, antrum, s/p biopsy (A)
      • CLO test: Positive
    • 2022-11-22 Pulmonary flow volume loop
      • Mild to moderate obstructive ventilatory impairment
    • 2022-11-22 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (99 - 24) / 99 = 75.76%
        • M-mode (Teichholz) = 76
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated both atria and RV, grade 1 LV diastolic dysfunction
      • Mild AR, MR, and PR, moderate to severe TR
      • Pulmonary hypertension
    • 2022-11-21 ECG
      • Sinus rhythm with 1st degree A-V block
      • Voltage criteria for left ventricular hypertrophy
      • ST & T wave abnormality, consider anterolateral ischemia
    • 2022-11-21 CXR
      • No cardiomegaly
      • Tortuosity of the aorta with atherosclerotic change.
      • Increased lung markings over both lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-11-16 Patho - nasopharyngeal/oropharyngeal biopsy
      • Tumor, soft palate, biopsy — Compatible with squamous cell carcinoma and candidiasis
      • The specimen submitted consisted of three small pieces of tumor tissue measuring up to 0.5 x 0.3 x 0.2 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections in one cassette.
      • Microscopically, the sections show a picture of ulcer with fungal hyphae and spores, morphology consistent with candidiasis and high grade (severe) dysplasia with pleomorphic and hyperchromatic nuclei and dyskeratosis. However, no convincing stromal tissue included in the limited specimen. According to histopathologic finding and clinical information (Show Chwan Memorail Hospital: pathlology revealed malignancy. Uvula, biopsy — Squamous cell carcinoma, moderately differentiated), it is compatible with squamous cell carcinoma, moderately differentiated. Closely follow up
      • Immunohistochemistry of P16(-)
    • 2022-11-15 Nasopharyngoscopy
      • soft palate cancer
  • consultation
    • 2022-11-24 Radiation Oncology
      • Q
        • After admitted, MRI showed : left soft palate tumor, T2N2M0. Abd echo showed some parts of pancreas blocked by bowel gas, especially head and tail. PES showed reflux esophagitis LA Classification grade A. Superficial gastritis, and gastric shallow ulcers. Under the impression of soft palate cancer, cT2N2M0, HPV pending, we suggest him to recevied surgery or CCRT. His daughter need opinion for radiotherpy. We need your help for further evaluation. Thank you very much!!
      • A
        • He has no genuine teeth now. CT-simulation will be arranged on 20221130. Plan to deliver 50 Gy/ 25 fx to the bil. neck lymphatic drainage area and orophayrnx. Then boost the soft palate tumor and LAPs to 70 Gy/ 35 fx. RT will start around 20221202 or 20221205. Thank you very much.
    • 2022-11-24 Cardiology
      • Q
        • This is a 91-year-old man with underlying hypertension and coronary artery disease under medication control for many years. No operation history. He had odynophagia for 3 months. Soft palate cancer was told at Show Chwan Hospital. He admitted to our ENT OPD for cancer work up. After work up, soft palate cancer stage IV was diagnosed.
        • We also arrange 2D echo which revealed Dilated both atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, pulmonary hypertension. PFT showed: Mild to moderate obstructive ventilatory impairment.
        • We request your consultation for further evaluation.
      • A
        • S
          • This patient suffered from soft palate cancer and was admitted to our hospital for evaluation about the treatment, including surgical, chemotherapy or radiotherapy. After admission, noted to have mild to modeate pulmonary hypertension while pre-OP heart function survey and CV had been consulted. However, they changed mind about surgical tratment and preferred CCRT at the meantime.
        • O
          • Lung function test: Mild to moderate obstructive ventilatory impairment
          • EChocardiography: M-mode(Teichholz) = 76; TR: moderate to severe; Max pressure gradient = 38 mmHg
            • Preserved LV and RV systolic function with normal wall motion
            • Dilated both atria and RV, grade 1 LV diastolic dysfunction
            • Mild AR, MR, and PR, moderate to severe TR
            • Pulmonary hypertension
        • Diagnosis:
          • mild to moderate pulmonary hypertension
        • Suggestion:
          • This patient currently had no signs of dyspnea, acute heart failure sign or chest pain. Since preserved LV systolic dysfunction noted, there was no acute contra-indication for surgical intervention.
            • If surgical treatment was arranged, may try pre-operative statin to prevent CAD attack, e.g. Short-term Atorvastatin 1/2# ~1# QD (20mg)
          • Since the pulmonary hypertension was only mild to moderate, and patient had no active symptom, conservative management and search for underlying cause are recommended.
            • The most obvious cause of pulmonary hypertension might be lung disease, since patient’s tricuspid valve showed no thickening at the meantime
            • Suspected Group 3: Pulmonary Hypertension Due to Lung Disease
              • may arrange chest CT to evaluate the lung parenchymal (group 3) and with contrast for pulmonary artery (artery intimal narrow, group 1 or thrombus group 4)
  • chemoimmunotherapy
    • 2022-12-14 - Erbitux (cetuximab) 250mg/m2 400mg 2hr (CCRT) dose 400 <- 600
      • premed - betamethasone 4mg + diphenhydramine 30mg
    • 2022-12-14 - Erbitux (cetuximab) 400mg/m2 600mg 2hr (CCRT)
      • premed - betamethasone 4mg + diphenhydramine 30mg

[note]

  • Cetuximab-Containing Combinations in Locally Advanced and Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma (Front. Oncol., 20 May 2019 https://doi.org/10.3389/fonc.2019.00383)
    • Cetuximab remains to date the only targeted therapy approved for the treatment of head and neck squamous cell carcinoma (HNSCC). The EGFR pathway plays a key role in the tumorigenesis and progression of this disease as well as in the resistance to radiotherapy (RT). While several anti-EGFR agents have been tested in HNSCC, cetuximab, an IgG1 subclass monoclonal antibody against EGFR, is the only drug with proven efficacy for the treatment of both locoregionally-advanced (LA) and recurrent/metastatic (R/M) disease. The addition of cetuximab to radiotherapy is a validated treatment option in LA-HNSCC. However, its use has been limited to patients who are considered unfit for standard of care chemoradiotherapy (CRT) with single agent cisplatin given the lack of direct comparison of these two regimens in randomized phase III trials and the inferiority suggested by metanalysis and phase II studies. The current use of cetuximab in HNSCC is about to change given the recent results from randomized prospective clinical trials in both the LA and R/M setting. Two phase III studies evaluating RT-cetuximab vs. CRT in Human Papillomavirus (HPV)-positive LA oropharyngeal squamous cell carcinoma (De-ESCALaTE and RTOG 1016) showed inferior overall survival and progression-free survival for RT-cetuximab combination, and therefore CRT with cisplatin remains the standard of care in this disease. In the R/M HNSCC, the EXTREME regimen has been the standard of care as first-line treatment for the past 10 years. However, the results from the KEYNOTE-048 study will likely position the anti-PD-1 agent pembrolizumab as the new first line treatment either alone or in combination with chemotherapy in this setting based on PD-L1 status. Interestingly, cetuximab-mediated immunogenicity through antibody dependent cell cytotoxicity (ADCC) has encouraged the evaluation of combined approaches with immune-checkpoint inhibitors in both LA and R/M-HNSCC settings. This article reviews the accumulated evidence on the role of cetuximab in HNSCC in the past decade, offering an overview of its current impact in the treatment of LA and R/M-HNSCC disease and its potential use in the era of immunotherapy.

[assessment]

  • During the past month, the patient’s liver and kidney functions have declined.

    • Creatinine
      • 2022-12-21 Creatinine 2.06 mg/dL
      • 2022-12-14 Creatinine 1.58 mg/dL
      • 2022-11-21 Creatinine 1.29 mg/dL
    • BUN
      • 2022-12-21 BUN 67 mg/dL
      • 2022-12-14 BUN 51 mg/dL
      • 2022-11-21 BUN 34 mg/dL
    • S-GPT/ALT
      • 2022-12-21 S-GPT/ALT 89 U/L
      • 2022-12-14 S-GPT/ALT 54 U/L
      • 2022-11-21 S-GPT/ALT 10 U/L
    • S-GOT/AST
      • 2022-12-21 S-GOT/AST 51 U/L
      • 2022-12-14 S-GOT/AST 36 U/L
      • 2022-11-21 S-GOT/AST 19 U/L
  • As the patient’s CrCl level is 17 mL/min according to the Cockcroft-Gault formula, it is recommended that the dosage of clarithromycin and amoxicillin be halved.

  • For patients with severely impaired kidney function, neither cisplatin nor carboplatin is recommended. Cetuximab is being administered as part of the patient’s treatment with CCRT.

  • In this patient, transthoracic echocardiography (2022-11-22) revealed dilated atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, and pulmonary hypertension. Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving cetuximab with radiation therapy or a cetuximab product with platinum-based therapy and fluorouracil. It is recommended to closely monitor serum electrolytes, including magnesium, potassium, and calcium, during and after cetuximab administration.

701448280

221222

{not completed}

  • exam findings
    • 2022-11-23 PD-L1 IHC
      • Tumor cell (TC) staining assessment: TC >= 10% and < 50%
      • Percentage of 28-8 expressing tumor cells (%TC): 30%
    • 2022-11-23 PD-L1 22C3
      • Tumor Proportion Score(TPS) assessment: <1%
        • Tumor Proportion Score(TPS): <1%
      • Combined Positive Score(CPS) assessment: <1
        • Combined Positive Score(CPS): <1
    • 2022-11-23 PD-L1 SP142
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
        • Tumor cell (TC) staining assessment: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): < 1 %
        • Tumor-infiltrating immune cell (IC) staining assessment: IC < 1%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): < 1 %
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-11-15 CT - abdomen
      • Regression of prior seen liver dome marginal enhanced tumor as compare with CT study on 2022-09-03.
      • Liver cirrhosis.
      • Paraaortic and mesentery lymph nodes.
      • Left lower lung nodule, suspected lung metastasis.
    • 2022-11-14 Nasopharyngoscopy
      • no obvious tumor mass noticed over hupopharynx
    • 2022-10-04 Patho - stomach biopsy
      • Stomach, upper body, biopsy — Chronic gastritis, H pylori NOT present
    • 2022-10-03 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Hypopharyngeal cancer, post CCRT, with esophageal inlet involvement
        • Esophageal varices, F1CbLi, RCS(-)
        • Superficial gastritis, s/p CLO test and biopsy at LC of upper body
        • Suspected Portal hypertensive gastropathy
        • Shallow duodenal ulcer, bulb
        • R/O Papillitis or periampullary lesion
        • Failure of endoscopy-guided NG insertion
      • Suggestion
        • Suggest surgical gastrostomy
        • Correlate with other clinical data for the endoscopic finding of enlargement of papilla
    • 2022-09-08 CT - abdomen
      • In favor of liver, lung and LNs metastases.
    • 2022-09-02 Whole body PET scan
      • Glucose hypermetabolism involving the right and posterior aspects of the hypopharynx with invasion to the the right thyroid cartilage and proximal portion of the esophagus, compatible with advanced hypopharyngeal malignancy. Please correlate with other clinical findings for further evaluation.
      • Glucose hypermetabolism in multiple bilateral neck lymph nodes, compatible with metastatic lymph nodes.
      • Glucose hypermetabolism in a a focal area in the dome of liver. Either liver metastasis or primary liver malignancy may show this picture.
      • Mild glucose hypermetabolism in the soft palate. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
      • Mild to moderate glucose hypermetabolism in the distal portion of the esophagus and mild glucose hypermetabolism in a focal area in the anterior aspect of right lower lung field. The nature is also to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
    • 2022-09-01 MRI - larynx
      • Imaging Report Form for Hypopharynx Carcinoma
        • Impression (Imaging stage) : T:T4(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2022-09-01 SONO - abdomen
      • Diagnosis
        • Propable Cirrhosis
        • Suspected regenerative nodules,bil
        • Right pleural effusion ,mild
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP,HBV,HCV
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
        • Because of cirrhosis ,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
    • 2022-09-01 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Hypopharygeal lesion extended to upper esophagus
        • Esophageal varices, F2CbLm
        • Duodenal ulcer scar, bulb
        • Portal hypertensive gastropathy
      • Suggestion
        • Suspected liver cirrhosis
    • 2022-08-22 Patho - nasopharyngeal/oropharyngeal biopsy
      • DIAGNOSIS
        • Soft palate, right, biopsy— squamous cell carcinoma, moderately differentiated (p16: -)
        • Posterior pharyngeal wall tumor, right, biopsy— high-grade dysplasia (p16: -)
      • Microscopically, section A shows moderately differentiated squamous cell carcinoma consisting of proliferation of atypical squamous cells with focal stromal invasion and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and some mitiotic activity. Section B show a small piece of high-grade dysplastic squamous cells.
      • Immunohistochemical stain reverals p16(-).
    • 2022-08-22 Nasopharyngoscopy
      • Findings
        • smooth nasopharynx, bulging of right lateral pharyngeal wall with obliteration of right pyriform sinus; posterior wall mass with partial necrotic tissue; suspect R vocal cord palsy; poor visualization of glottis.
      • Diagnosis/Conclusion
        • suspect R hypopharyngeal cancer
  • consultation
    • 2022-09-05 Hemato-Oncology
      • Q
        • We request your consultation for further management.
      • A
        • Impression:
          • advanced hypopharyngeal malignancy with invasion to the the right thyroid cartilage and proximal portion of the esophagus, cT:T4N3M0, stage IVB, soft palate biopsy SCC
          • Propable Cirrhosis, Suspected regenerative nodules, bil, Right pleural effusion, mild
        • Suggestion:
          • Since a case of iver cirrhosis, the primary tumor of liver is needed to be considered. Triple phase liver CT and AFP would be helpful.
          • CCRT is indicated. Then, consult RT for further evaluation.
          • May arrange my OPD if discharge.
    • 2022-09-02 Oral and Maxillofacial Surgery
      • Q
        • This 50 y/o man is a case of hypopharyngeal cancer. The patient suffered from lumping throat on and off and hoarseness for 2 weeks. Body weight loss was noted too. He had smoking habit 1 pack/day, beer about 3 bottle/day, and betel nuts about 2pack/day.
        • He was admission due to right vocal palsy and soft palate tumor biopsy revealed: soft palate squamous cell carcinoma, moderately differentiated (p16: -); posterior pharyngeal wall high-grade dysplasia (p16: -).
        • After admission, cancer work up was arranged. The neck MRI on 9/1 which revealed the tumor invasion to hypopharynx, thyroid cartilage, cricoid cartilage and extended to esophagus, cT4bN3M0, stage IVB. The abdominal sono revealed suspect liver cirrhosis, and right pleural effusion.
        • We request your consultation for pre-chemotherapy dental evaluaion.
      • A
        • For pre-chemotherapy dental evaluaion.
        • O:
          • Hopeless tooth of 11, 21, 28, 43, 44, 45 were noted.
          • Panoramic film revealed severe periodontitis of full mouth.
          • Severe poor oral hygiene.
        • P:
          • Take panoramic X-ray film to check up.
          • Explain findings and treatment plan to the patient and his brother.
          • Suggest extraction of tooth 11, 21, 28, 43, 44, 45 before chemotherapy and radiotherapy.
        • The risk of osteomyelitis after tooth extraction or implantation after radiotherapy has been informed, the patient said that he did not want to have the tooth extracted, and he had to think again

700365018

221221

{not completed}

  • lab data
    • 2022-10-19 HBsAg (NMed) Negative
    • 2022-10-19 HBsAg Value (NMed) 0.396
    • 2022-10-19 Anti-HBc (NMed) Positive
    • 2022-10-19 Anti-HBc Value (NMed) 0.00702
    • 2022-10-19 Anti-HCV (NMed) Negative
    • 2022-10-19 Anti-HCV Value (NMed) 0.0379
  • exam findings
    • 2022-10-26 All-RAS + BRAF mutations assay
      • All-RAS: Detected (KRAS codon 12 GGT>GTT, p.G12V
      • BRAF: There was no variant detected in the BRAF gene.
    • 2022-10-25 Tc-99m MDP whole body bone scan
      • Increased activity in the middle T-spines and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2022-10-24 Whole body PET scan
      • Increased FDG uptake in the rectal region and peripheral lymph nodes, compatible with rectal cancer with regional lymph nodes metastases.
      • Glucose hypermetabolic lesions in bilateral retromolar and submandibular lymph nodes, the nature is to be determined (reactive nodes, distant lymph nodes metastases, lymphoma, or others ?), suggesting biopsy for investigation.
      • Increased FDG uptake in bilateral palatine tonsils, probably a chronic inflammation/infection process.
      • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive nodes.
      • Malignant neoplasm of rectum with regional lymph nodes metastases, cTxN2M0, by this F-18-FDG PET/CT scan.
    • 2022-10-18 CT - abdomen
      • Clinical history: 59 y/o male patient with rectal cancer.
      • With and without contrast enhancement CT of whole abdomen:
        • Thickening wall at the rectum, suspected rectal malignancy.
        • Presence of perirectal lymph nodes.
        • Unremarkable change of the liver, spleen, pancreas and both kidneys.
        • No enlarged lymph node in the paraaortic region.
        • No ascites.
        • Fibrotic infiltrates in bilateral lung apex.
        • Suspicious right upper lung nodule, suggest follow up.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE: IIIC__(Stage_value)
    • 2022-09-20 Patho - colon biopsy
      • Large intestine, rectum, 5cm to 10cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm.
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2020-09-20 Colonoscopy
      • Findings
        • The scope reach the cecum under fair colon preparation. Many liquid fece with seeds were noted, which blocked almost half of the colon.
        • One semi-annular rectal tumor was noted from 5cm AAV to 10cm AAV. Biopsy was done.
      • Diagnosis
        • Highly suspected rectal cancer, s/p biopsy
        • Suboptimal study
      • Suggestion
        • F/U pathology report
        • CRS OPD follow up
        • Small lesions may be missed due to suboptimal bowel preparation.
      • Complication
        • No immediate complication
  • consultation
    • 2022-10-20 Hemato-Oncology
      • Q
        • After fully explained of the condition, pre-op CCRT first followed by surgical treatment was suggested. We needs your expert experience for evaluation of pre-op CCRT. Thanks a lot !!
      • A
        • I would like to take over this case for neoadjuvant CCRT for his rectal cancer with perirectal lymph nodes, cstage T3N2bM0.
    • 2022-10-19 Radiation Oncology
      • Q
        • This 59 y/o male patient sufferre from loose stool and blood in stool for 1 year. Tumor maker with CEA showed 7.18 ng/mL. Colonscopy was performed on 2022/09/20 and revealed highly suspected rectal cancer, 5~10 cm from anal verge, s/p biopsy. Biopsy pathology showed adenocarcinoma, moderately differentiated. Lab data showed anemia (6.6 g/dL) and blood transfusion was done. Abdominal CT revealed rectal cancer with perirectal lymph nodes, cstage T3N2bM0, stage IIIC.
      • A
        • Pre-op CCRT is indicated. CT-simulation will be arranged on 20221024. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 20221026 or 27.
  • chemotherapy
    • 2022-12-20 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 620mg 2hr + fluorouracil 400mg/m2 620mg 2hr + fluorouracil 2400mg/m2 3700mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
    • 2022-12-06
    • 2022-11-21
    • 2022-11-07

[assessment]

  • According to the available lab data, the levels of MCV, MCH, and MCHC have been frequently low since July 2022.
  • Low MCV, MCH, and MCHC can be caused by anemia which could include iron-deficiency anemia and anemia due to chronic disease.
  • Thalassemia can also affect the production of hemoglobin, leading to low MCV, MCH, and MCHC.
  • Foliromin (ferrous sodium citrate) has been prescribed since mid-Nov 2022, but the readings of the MCV, MCH, and MCHC have only shown a minimal improvement.
  • As far as FOLFOX treatment is concerned, there are no issues.

701446872

221221

  • exam findings
    • 2022-11-29, -11-03, -11-01 Body fluid cytology - ascites
      • negative
    • 2022-10-21 CT - abdomen
      • History: Gastric adenocarcinoma of proximal middle body great curvature, metastasis to adjacent omentum pT4aN1M1 stage IV post total gastrectomy with lymphadenectomy of station 1 to 12A and 14V, Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-07.
      • Findings:
        • S/P total gastrectomy.
        • S/P Jackson-Pratt drainage tube insertion from right and left abdominal wall.
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P total gastrectomy.
        • There is no evidence of tumor recurrence.
    • 2022-09-08 Patho - stomach subtotal/total (tumor)
      • PATHOLOGIC DIAGNOSIS
        • Tumor, stomach, total gastrectomy — Poorly cohesive carcinoma
        • Margins, bilateral cutting ends, ditto — Free of tumor invasion
        • Lymph nodes, LN 1, ditto — Free of tumor metastasis (0/7)
        • Lymph nodes, LN 2, ditto — Free of tumor metastasis (0/7)
        • Lymph nodes, LN 3, ditto — Tumor metastasis (1/19) with isolated tumor cells and tumor deposits
        • Lymph nodes, LN 4, ditto — Free of tumor metastasis (0/20)
        • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/1)
        • Lymph nodes, LN 6, ditto — Free of tumor metastasis (0/4)
        • Lymph nodes, LN 7,8,9,11,12, ditto — Free of tumor metastasis (0/8)
        • Lymph nodes, LN 10, ditto — Free of tumor metastasis (0/5)
        • Lymph nodes, LN 14v, ditto — Fat only
        • Omentum, omentectomy — Free of tumor invasion
        • AJCC Pathologic staging — pT4aN1M1, stage IV
      • MACROSCOPIC EXAMINATION
        • Specimen type: Stomach, lymph node and omentum
        • Specimen size: 19.3 x 10.2 x 1.3 cm in size, 189 gm in weight
        • Number of lesions: Solitary
        • Tumor site: middle body, greater curvature
        • Tumor size: 1.2 x 0.8 cm
        • Tumor configuration: ulcerative tumor
        • Omentum: 38 x 16 x 1.2 cm, no significant change
      • MICROSCOPIC EXAMINATION
        • Histologic type: Poorly cohesive carcinoma
        • Histologic grade: Grade 3, poorly differentiated
        • Depth of tumor invasion: serosa layer
        • Lymph nodes: tumor metastasis (1/71) in total number without extracapsular extension
        • Omentum: free of tumor invasion
        • AJCC Pathologic Staging: pT4aN1M1
        • Bilateral resection margins: Free of tumor invasion
        • Additional pathologic findings: ulcer with mild intestinal metaplasia
        • Perineural invasion: Present
        • Lymphovascular space invasion: Present
        • Immunohistochemical stains:
          • CAM5.2(+) for serosal invasion
          • CK(+) for isolate tumor cells within lymph node and tumor deposits in LN3
          • HER2(-, Dako score 0 ) for tumor
    • 2022-08-22 CT - abdomen
      • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T1a(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
    • 2022-08-16 Patho - stomach biopsy
      • Stomach, antrum to lower body, biopsy— chronic gastritis with intestinal metaplasia. No H.pylori present
        • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate and intestinal metaplasia. No Helicobacter-like bacillus is seen.
      • Stomach, middle body, biopsy— poorly differentiated adenocarcinoma
        • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of atypical tumor cells arranged in solid architecture. The tumor shows pabundant cytoplasm and pushing nuclei with signet ring cell-like picture. No H.pylori is seen.
        • Immunohistochemical stain reveals CK(+) at tumor cells.
    • 2022-08-15 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal phleboectasia, lower and middle esophagus
        • Chronic superficial gastritis, s/p CLO
        • Gastric ulcer, A2-H1, middle body, suspected dysplastic or malignant lesion, s/p biopsy (A)
        • Probable intestinal metaplasia, antrum to lower body, s/p biopsy (B)
        • Gastric xanthoma
        • Bile reflux in stomach
      • Suggestion
        • PPI therapy
        • Pursue CLO test and pathology result
        • EGD follow-up is indicated
  • chemoimmunotherapy
    • 2022-12-12 - oxaliplatin 50mg/m2 75mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2500mg/m2 3700mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-11-29 - oxaliplatin 50mg/m2 75mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2500mg/m2 3760mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-31 - oxaliplatin 50mg/m2 70mg 2hr + leucovorin 400mg/m2 625mg 2hr + fluorouracil 2500mg/m2 3800mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-21 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 625mg 2hr + fluorouracil 2500mg/m2 4000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 1mg
    • 2022-09-14 - mitomycin-c 16mg/m2 25mg 2hr D2 + [fluorouracil 500mg/m2 780mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr D1-5
      • premed - betamethasone 4mg

==========

2022-12-21

  • The bowl movement in this patient reached 3 times on 2022-12-20. It is recommended to hold the Through (sennoside) temperately and monitor the changes in the bowl movement these days.

701464956

221221

{drug identification}

A request has been made for us to identify drugs for 10 items.

In total, 9 items have been identified as follows, with 1 item remaining unidentified.

  • Meptin-mini (procaterol 25mcg)
  • Nexium (esomeprazole 40mg)
  • Tareg (valsartan 80mg)
  • Norvasc (amlodipine 5mg)
  • Solaxin (chlorzoxazone 200mg)
  • Rovo (repaglinide 1mg)
  • Aricept (donepezil 10mg)
  • Gaslan (dimethicone 40mg)
  • Medicon-A (dextromethorphan 20mg)

These drugs will be sent back to ward by the in-hospital porter.

701428029

221220

  • diagnosis - 20221130 discharge note
    • Malignant neoplasm of sigmoid colon
    • S-colon adenocarcinoma with reginal and distant lymph nodes and hepatic metastasis, T4N2M1a, stage IV s/p T-colostomy.
    • hepatitis B anti-Hbc :positive
  • past history
    • DM with diet control
    • Denied hypertension, CAD, CHF, Cancer
    • OP: Nil   
  • family history
    • Denied hypertension, DM, CAD, CHF, Cancer history with famliy
  • exam findings
    • 2022-09-22 CT - abdomen
      • History and indication: Malignant neoplasm of sigmoid colon
      • Findings
        • Mild regression of S-colon cancer with liver metastases. S/P colostomy.
        • Renal cysts (up to 2.1cm).
        • Normal appearance of spleen, pancreas, adrenals.
        • Normal appearance of gallbladder.
        • Patency of portal vein.
        • Intact bony structures.
        • No ascites.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • No abnormal density at bilateral basal lungs.
      • IMP: -Mild regression of S-colon cancer with liver metastases.
    • 2022-06-29 CT - chest
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1b(M_value) STAGE:____(Stage_value)
    • 2022-06-29 Patho - colon biopsy
      • Sigmoid colon, 20 cm AAV, biopsy — Adenocarcinoma
      • The sections show a picture of adenocarcinoma, composed of moderately differentiated columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with subtle desmoplastic stromal reaction.
    • 2022-06-28 Sigmoidoscopy
      • Findings
        • The scope reach the 20cm AAV
        • One tumor with luminal narrowing was noted at S-colon (20cm AAV), s/p biopsy
      • Diagnosis
        • Highly suspect colon cancer with luminal narrowing, S-colon (20cm AAV), s/p biopsy
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
  • consultation
    • 2022-07-07 Hemato-Oncology
      • Q
        • This is a 55y/o man with PMH of DM under diet control. This time he was admitted due to S colon tumor with reginonal lymphadnopathy and several hepatic metastasis. Due to poor intake and prominent obstructive symptoms, after discussing with the patient, he underwent T-loop colostomy and port A insertion. Now that the patient is relatively stable with much improved of the previous symptoms, OP wound and colostomy site with no infection signs, we would like to consult you for further treatment.
      • A
        • Impression:
          • Sigmoid colon cancer with regional and distant LNs and hepatic metastases T4N2M1a s/p T-loop colostomy and port A insertion
          • COVID-19 infection
          • DM
        • Suggestion:
          • We will discuss with patient about further chemotherapy. We may take over this case
          • Pending AntiHbc, HbsAg, Anti-HCV, CEA data
          • Pening colon patholgy for MMR IHC stain (MLH1、MSH2、MSH6、PMS2) and All RAS mutation survey
          • Thanks for your consultation. If there is any problem, please feel free to let us known.
  • surgical operation
    • 2022-06-30 T-loop colostomy
  • chemotherapy
    • 2022-12-19 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-11-28 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-11-14 bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5650mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-10-31 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2800mg/m2 5600mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-10-17 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 370mg 90min + leucovorin 400mg/m2 820mg 2hr + fluorouracil 2800mg/m2 5700mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-09-26 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-09-12 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-08-29 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 340mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5320mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-08-16 bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 340mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5320mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + atropine 1mg
    • 2022-08-03 irinotecan 180mg/m2 330mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5275mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO
    • 2022-07-20 irinotecan 180mg/m2 330mg 90min + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO
    • 2022-07-05 irinotecan 160mg/m2 290mg 90min + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg + atropine 1mg + aprepitant 125mg PO

701006949

221219

{not completed}

  • exam findings
    • 2022-12-12 Chest PA + Lat LT
      • Diffuse osteoblastic change of the T-and L-spine are suspected. Please correlate with bone scan.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-10-24 - Tc-99m MDP whole body bone scan with SPECT
      • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed inhomogenously increased activity in the skull, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, clavicles, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, humeri and femurs.
      • IMPRESSION: Some of the previous bone lesions including the left rib cage, some T- and L-spine, right S-I joint, and left femoral trochanters come to slightly more evident compared with the previus study on 2022-03-31, suggesting metastatic bone disease in progression.
    • 2022-10-13 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • Increased pulmonary vasculature is found.
    • 2022-10-12 CT - abdomen
      • Findings:
        • There is a newly-developed hypodense lesion 1 cm in S4/8 dome of the liver at non-enhanced CT and that may be metastasis? Please correlate with MRI.
        • Presence of gallbladder stone.
        • There are few hyperdense lesions in the distal CBD that are c/w distal CBD stones.
        • Bilateral renal cysts (up to 1.1 cm).
        • Diffuse osteoblastic bony metastases with L2 compression fracture.
        • S/P colostomy at the sigmoid colon.
        • s/p Abdominal-perineal resection.
      • Impression:
        • Metastasis 1 cm in S4/8 of the liver is highly suspected. Please correlate with MRI.
        • Few gallstones and distal CBD stones.
    • 2022-03-31 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed inhomogenously increased activity in the skull, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, clavicles, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, humeri and femurs.
      • IMPRESSION: The scintigraphic findings are compatible with diffuse bone metastases.
    • 2022-03-01 KUB
      • Presence of ileus.
      • Heterogeneous density of bony structures.
      • Compression fracture of L2.
      • A calcified spot at RUQ.
    • 2022-02-24 Patho - colon segmental resection for tumors
      • PATHOLOGIC DIAGNOSIS
        • Lower rectum, laparoscopic abdominal perineal resection —- Metastatic adenocarcinoma, compatible with prostatic acinar adenocarcinoma, Gleason score 4 + 5 = 9, with rectum invasion
        • Bilateral resection margins — Free
        • Lymph node, mesocolic, dissection —- Tumor present (2/7) without extracapsular extension (0/2)
        • AJCC 8th edition Pathology stage (prostatic cancer) — pT4N1(cM1b: by CT finding), stage IVB
      • MACROSCOPIC EXAMINATION
        • Operation procedure: laparoscopic abdominal perineal resection
        • Specimen site: lower rectum, 1.5 cm above dentate line
        • Specimen size: 16.5 cm in length including a portion of skin measuring 1.2 cm in length
        • Tumor size: annularly ulcerated, 4.5 x 2.5 cm
        • Tumor location: 8.5 cm and 4.0 cm away from the two resection margins, respectively
        • Depth of invasion grossly: perirectal fat tissue
        • Mucosa elsewhere: congestion, ulcer
        • Another segment of unremarkable colon measuring 6.5 cm in length is reveived
        • Representative sections are taken and labeled as: A1-2: bilateral resection margin; A3: colon, non-tumor; A4-9: tumor; A10-13 and X1-30: lymph node, mesocolic.
      • MICROSCOPIC EXAMINATION
        • Histology: prostatic acinar adenocarcinoma, Gleason score 4 + 5 = 9
        • Depth of invasion: rectal wall to mucosa
        • Angiolymphatic invasion: Present
        • Perineural invasion: Present.
        • Lymph node metastasis, mesocolic: tumor present (2/7)
        • Extranodal involvement: Not identified
        • Pathologic Stage Classification (prostatic cancer): pT4N1 (cM1b: by CT finding), stage IVB
        • Type of polyp in which invasive carcinoma arose: N/A
        • Immunohistochemistry: EGFR(+), CK7(-), CK20(-), PSA(+, focal), CDX-2(+), CD56(-)
    • 2022-01-25 CT - abdomen
      • S/P colostomy. Suggest follow up.
      • Lymph nodes in the mediastinum and right hilar region, suspected lymph node metastasis. Stationary.
      • Gallbladder stone.
      • Intralumal hyperdense lesions in the CBD, suspected CBD stones.
      • Bilateral renal cysts.
      • Ascending colon diverticula.
      • Bone metastasis. L2 compression fracture.
    • 2022-01-25 CXR
      • Ground glass opacity in LLL.
      • Interstitial pattern at right lung.
      • Presence of ileus.
      • Heterogeneous density of bony structures.
    • 2022-01-07 Bronchodilator Test
      • Mild obstructive ventilatory impairment with significant bronchodilator response
    • 2022-01-07 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 29) / 105 = 72.38%
        • M-mode (Teichholz) = 73
      • Normal LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with trivial AR; mild TR.
      • Dilated aortic root and proximal ascending aorta (38mm) with mild calcification.
    • 2021-11-22, -11-03 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2021-10-12 Patho - colon biopsy
      • Colon tumor, 1 cm above dentate line, biopsy — Adenocarcinoma, pooylr differentiated
      • Microscopically, the sections show a picture of poorly-differentiated adenocarcinoma characterized by nest or individual tumor cells infiltration.
      • Immunohistochemistry shows CK(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
    • 2021-10-12 Colonoscopy
      • Rectal tumor, 1cm above dentate line, with luminal narrowing, s/p biopsy
      • Mixed hemorrhoid
    • 2021-10-07 CT - abdomen
      • History and indication: suspected colon cancer survey
      • Findings
        • Enlargement of prostate.
        • Wall thickening of rectum with adjacent fat stranding.
        • Multiple bony metastases.
        • Some LNs at pelvic cavity and paraaortic region.
        • A calcified spot (1.2cm) at gallbladder fossa.
        • Small renal cysts.
        • Left minimal pleural effusion. Some ground glass opacities at bil. lungs. A nodule at LLL.
        • Gallbladder stone (0.8cm).
        • Atherosclerosis of aorta, iliac, coronary arteries.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
    • 2021-09-29 MRI - L-spine
      • Bony metastasis in T12-S4 vertebral bodies and bilateral iliac wings.
      • Multiple para-aortic metastatic LAPs.
      • Lumbar spondylosis.
    • 2021-09-28 CT - chest
      • no evidence lung infection. moderate centrilobular emphysema in both upper lobes of lungs. no lung tumor.
      • extensive bony lesion, metastasis or hematogical disorder.
      • extensive LAD CAD.
    • 2021-09-23 CXR
      • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta?
      • mild enlarged cardiac silhoutte
      • Platelike lung atelectasis over Rt midlung zone hazy areas of increased opacity (ground-glass opacitie) over Lt lower lung zone
  • chemoimmunotherapy
    • 2022-11-14 - Abraxane (nab-paclitaxel) 75mg/m2 100mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 1mg (palliative, for prostate cancer)
    • 2021-12-06 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-29 - fluorouracil 200mg/m2 340mg 24hr (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-22 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-08 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-01 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg

701070156

221219

  • diagnosis - 2022-11-09 discharge note
    • Malignant neoplasm of cervix uteri, unspecified
    • Carcinoma of the uterine cervix, stage T1N1M0, stage IIIB s/p CCRT with recurrence and paraaortic lymph node metastasis with bone invasion
    • hepatitis B of anti-Hbc : positive
    • Hyperkalemia
    • Hyponatremia
  • family history
    • Mother died of cervical cancer when 53 y/o.
    • There is no family history of, hypertension, mental diseases or asthma.
    • First older sister diagnosed of diabetes.
  • exam findings
    • 2022-11-08, -10-31, -10-28, -09-22 KUB
      • Wedge deformity and total collapse at right lateral aspect of L4 vertebral body and suggestive osteolytic lesion at right lateral aspect of L3 vertebral body are noted that are c/w bony metastase after correlate with CT.
      • scoliosis of L-spine with convex to left side
      • Fecal material store in the colon.
    • 2022-11-07, -10-21, -09-26, -08-30 CXR
      • Enlargement of cardiac silhouette.
    • 2022-10-11 Tc-99m MDP whole body bone scan
      • Increased activity in the lower L-spines. Bone metastases should be watched out.
      • Increased activity in the sacrum and right S-I joint. Either degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
      • A faint hot spot in the anterior aspect of right 6th rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
    • 2022-09-21 CT - abdomen
      • Findings
        • osteolytic lesions in right lateral aspect of L3 and L4 vertebral bodies with right lateral extension and invasion to right psoas muscle, about 122.8mm.
        • Tumor encasement of the right internal and external iliac arteries was noted. Right hydornephrosis and right hydroureter were also noted.
      • IMP:
        • tumors in the right paraspinal region.
        • rihgt hydronephrosis and right hydroureter
    • 2022-09-21 ECG
      • Normal sinus rhythm
      • Right bundle branch block
      • Abnormal ECG
    • 2022-08-26 ECG
      • Normal sinus rhythm
      • Incomplete right bundle branch block
      • Cannot rule out Inferior infarct, age undetermined
      • ST & T wave abnormality, consider anterior ischemia
      • Abnormal ECG
    • 2022-08-19 CT - abdomen
      • History:
        • 2022/08/18 right hip pain radiated to foot for a peroid of time
        • 2021/11 visited our gyn OPD:
          • Carcinoma of the uterine cervix, stage T1N1M0, stage IIIB
          • Completion of radiotherapy on 2015-04-21. Suspicious paraaortic lymph node metastasis.
        • 2021/11 MRI here showed suspect recurrence
        • She said she has received C/T at Tailand this year, result?
      • Indication: Suspected recurrent tumor in right paraspinal region and L3-4 invasion
      • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is osteolytic lesion in right lateral aspect of L3 and L4 vertebral body with right lateral extension and invaded into right psoas muscle, causing a heterogeneous poor enhancing soft tissue mass lesion (the cranial-caudal diemsnion:12.5 cm) that is c/w bony metastasis.
          • In addition, right external iliac artery shows small size that is c/w encasement by the metastatic mass in right psoas muscle.
        • There is right side hydroureteronephrosis and the etiology is due to passive comprssion of right M/3 ureter by the upper described metastatic mass in right psoas muscle .
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Bony metastases in L3 and L4 vertebral body with metastatic mass in right psoas muscle.
    • 2022-08-15 Gynecologic ultrasonography
      • Bilateral adnexae free
      • EM 2.5mm
    • 2021-11-29 MRI - pelvis
      • Clinical history: 56 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB.
      • Cervical cancer s/p RT.
      • Infiltrative soft tissue tumor, 4.6x9.8cm in right paraspinal region with L3-4 invasion, suspected metastasis.
    • 2021-11-25 Gynecologic ultrasonography
      • Bilateral adnexae free
      • EM 1.6mm
    • 2017-12-25 CT - pelvis
      • Clinical history: 52 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, hx of appendectomy/LC for ectopic pregnancy.
      • Findings
        • Lymph node in left paraaortic region, up to 1.25cm, r/o metastatic lymph node. Progression.
      • Impression:
        • Cervical cancer s/p RT, progression of paraaortic lymph node (1.25cm).
    • 2017-07-20 CT - pelvis
      • Clinical history: 52 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, hx of appendectomy∕LC for ectopic pregnancy.
      • Findings
        • Lymph node in left paraaortic region, up to 1.03cm, r/o metastatic lymph node.
      • Impression:
        • Cervical cancer s/p RT, regression of pelvic lymph nodes. But presence of paraaortic lymph node, 1.03cm, suggest follow up study.
    • 2017-06-26 Mammography
      • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative. - annual screening.
  • consultation
    • 2022-08-29 Radiation Oncology
      • Q
        • Patient could not understand our language very well. She said she has received C/T and has MST from Tailand on 2022 ?? This time ,she wa admitted for further management.
      • A
        • S: For radiotherapy due to L3, L4, and right psoas muscle metastases with pain.
          • The patient only received ICRT x 4 fractions at TSGH due to severe left abdomen pain during the 5th ICRT procedure.
          • Chemotherapy: 2015-2-2; 2015-3-2; 2015-4-9
          • PI: This is a case of squamous cell carcinoma of the uterine cervix, initial stage T1N1M0, stage IIIB, s/p CCRT, with L3, L4, and right psoas muscle metastases. The patient suffered from pain of right flank area. She said ever received radiotherapy at Bangkok in 2022.
          • Hx of appendectomy/LC for ectopic pregnancy.
          • Family Hx: mother (died of cervical cancer)
        • O:
          • ECOG: 2
          • PE: neck and bil SCF: neg; bil low limbs: no edema; pain of right flank area.
        • A:
          • Squamous cell carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, s/p CCRT, with L3, L4, and right psoas muscle metastases.
        • P:
          • The patient said she ever received radiotherapy of the right flank area at Bangkok in 2022. We need to understand the details of radiotherapy at Bangkok. She is applying these information. RTC: 2022-08-31.
  • chemoimmunotherapy
    • 2022-11-21 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
    • 2022-10-25 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
    • 2022-09-29 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
    • 2022-09-07 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr

[assessment]

  • In the lab data collected on 2022-12-18, there were no extreme abnormalities that warranted postponing the chemotherapy schedule.
  • It was noted that the blood pressure dropped to 90/50 at dusk on 2022-12-18. Prior to the administration of the chemotherapy, the vital signs should be within a fairly stable range.

701236803

221219

  • diagnosis - 20221216 admission note
    • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
    • Pleural effusion, not elsewhere classified
    • Pneumonia, unspecified organism
    • Localized enlarged lymph nodes
    • Essential (primary) hypertension
  • exam findings
    • 2022-12-18 CXR
      • approriately positioned endotracheal tube in place
      • Lt internal jugular central venous catheter in place with tip projecting over Rt paratracheal space
      • regression of Lt pleural effusion s/p chest tubes placement
      • Port-A catheter inserted into SVC junction via left subclavian vein.
      • extensive hazy increased opacity in the right mid to lower lung zone with obscuration of silhouttes of the right left heart border
    • 2022-12-16 ECG
      • Sinus tachycardia
      • Low voltage QRS
      • Borderline ECG
    • 2022-12-06 Cell Block Cytology
      • 50 cc brown turbid pleural effusion - Atypia
      • The smears and cell block show small lymphocytes and reactive mesothelial cells.
      • Immunocytochemistry shows CD20(+) > CD3(+) lymphocytes, Bcl-6(+/-, equivocal) and CD10(+, focal) for lymphocytes, follicular lymphoma can not be excluded entirely. Follow up
    • 2022-12-06 SONO - chest
      • Right thorax: minimal amount pleural effusion.
      • Left thorax: moderate amount, serosanguinous pleural effusion s/p insertion of 14 Fr. pig-tail catheter and fixed at 15cm.
    • 2022-12-05 CXR
      • S/P port-A implantation.
      • Hypoinflation of both lung is noted.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
      • Left pleura effusion is noted.
      • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • 2022-11-22 Patho - peritoneum biopsy
      • Abdomen, CT-guide biopsy— Follicular lymphoma
      • Histology type: B-cell neoplasms - Follicular lymphoma
      • Immunohistochemical stain profiles: CD20(+), CD3(-), CD10(+), Bcl-2(+), Bcl-6(+), CD5(+), CD23(-), cyclin D1(-).
    • 2022-11-21 CXR
      • Hypoinflation of both lung is noted.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
    • 2022-10-26 Whole body PET scan
      • Glucose hypermetabolic lesions in the left NP region and left axillary lymph nodes come to less evident, and glucose hypermetabolic lesions in bilateral cervical lymph nodes, left iliac bone, right pubic bone and right femur disappear compared with the previous study on 2020-09-17, indicating response to current therapy.
      • However, glucose hypermetabolic lesions in bilateral supraclavicular and left infraclavicular lymph nodes, bilateral mediastinal lymph nodes, abdominal and pelvic lymph nodes, and spleen become markedly more prominent, suggesting lymphoma in progression.
      • B-cell lymphoma s/p treatment with residual/recurrent tumor involving lymph node regions on both sides of the diaphragm and spleen, c-stage IIIS (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2022-10-25 Neurosonology
      • Mild atherosclerosis in Rt ECA.
      • Normal pulsatility index (PI) in detected intracranial artery system.
      • Inadequate total blood flow volume of bilateral Vertebral artery (85 ml/min), indicating Vertebrobasilar insufficiency (VBI).
    • 2022-10-25 Brainstem Auditory Evoked Potentials, BAEP
      • This abnormal BAEP study suggests a peripheral sensori-neural hearing disorder on both sides.
    • 2022-10-01 CT - chest
      • Indication:
        • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
        • Localized enlarged lymph nodes
        • Essential (primary) hypertension
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
          • Lymphadenopathy at bilateral thoracic inlet and superior mediastinum. In comparison with CT dated on 2022-03-19, the lesion enlarged.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Lymphadenopathy at paraaortic and pelvic floor is found.
          • The urinary bladder is well distended without soft tissue lesion.
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • IMp:
        • Lymphadenopathy at bilateral thoracic inlet and mediastinum and abdominal paraaortic and pelvic floor, in enlargement.
    • 2022-09-15 Nasopharyngoscopy
      • Findings
        • bi nasal cavity clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function; no tumor found at bi pharynx; mucus coating on left nasopharynx, local treatment done
      • Conclusion
        • Head neck lymphoma (nasopharynx and neck) s/p chemotherapy, No evidence of tumor recurrence
    • 2022-06-23, -03-03, -01-06, 2021-10-14, -08-12, -06-10, -05-18 Nasopharyngoscopy
      • Findings
        • bi nasal cavity clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function; no tumor found at bi pharynx
      • Conclusion
        • Head neck lymphoma (nasopharynx and neck) s/p chemotherapy, No evidence of tumor recurrence
    • 2022-03-19 CT - chest
      • S/p port-A placement with its tip at Superior vena cava
      • No evidence of recurrent/residual lymphadenopathy in the study.
    • 2021-09-09 CT - chest
      • NO evidence of lymphadenopathy in the current study.
      • Minimal right lower lobe and left lower lobe lung collpase.
    • 2021-04-12 CT - neck
      • a small nodular lesion in the right parotid gland
      • suspicious a nodular lesion in the right thyroid gland.
    • 2020-11-30 CT - neck
      • a nodular lesion in the right parotid gland.
      • regression of the left nasopharyngeal tumor
    • 2020-09-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 17) / 100 = 83%
        • M-mode (Teichholz) = 83
      • Normal LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
      • Mildly dilated proximal ascending aorta (35mm).
    • 2020-09-17 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma involving the left aspect of the nasopharynx, multiple lymph nodes on both sides of the diaphragm and multiple bones as mentioned above. Please correlate with other clinical findings for further evaluation.
    • 2020-09-16 CXR
      • Hypoinflation of both lung is noted.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
    • 2020-09-16 Patho - bone marrow biopsy
      • Bone marrow, biopsy — lymphoid aggregation
      • Microscopically, it shows 40% of cellularity with 2:2 or M:E ratio, trilineage cellular component, mature megakaryocyts and presence of lymphoid aggregations.
      • Immunohistochemical stain reveals CD20(+), Bcl-2(+ at aggregation), CD10(focal+), CD138(1~2%), CD117(-), Bcl-6(-), CD34(-), CYCLIN D1(-), MPO (+), CD71(+).
      • NOTE: Clinical correlation is essential.
    • 2020-09-04 Patho - nasopharyngeal/oropharyngeal biopsy
      • Nasopharynx, left, biopsy— B cell type lymphoma, low grade
      • Microscopically, it shows B cell type lymphoma characterized by proliferation of low-grade B cell type lymphoid cells. The follicular architecture is not significant. Mitoses are not common.
      • Immunohistochemical stain reveals CD20(+), CK(-), CD10(+), Bcl-2(+), cyclin D1(-), CD3 (+ at background T cell), MUM1(-), C-myc(-), CD23(-), CD5(+), Ki67 index: < or = 10%.
      • NOTE: The result of IHC stain is in favor of follicular lymphoma.
    • 2020-09-03 Nasopharyngoscopy
      • Findings: left nasopharynx mild swelling, biopsy done
      • Diagnosis: left nasopharyngeal lesion
    • 2020-08-28 CT - neck
      • Findings
        • a heterogeneous enhancing lesion, about 22mm in the longest axis, in the left nasopharynx.
        • enlarged lymph nodes in the bilateral posterior cervical spaces, and left supraclavicular fossa.
      • IMP: suspected left NPC with bilateral neck enlarged lymph nodes
    • 2020-05-12 Patho - lymph node region resection
      • Lymph node, level IV, V, excision — reactive follicular hyperplasia
      • Microscopically, sections of regional lymph nodes show reactive follicular hyperplasia characterized by prominent uniformly spaced but enlarged germinal centers.They vary considerably in size and shape,and display dumbbell, hourglass,round or bizarre configurations. The mantle zone and germinal centers are sharply demarcated in a reactive follicle. The germinal centers are prominent and hyperplastic and comprise a mixture of small and large lymphoid cells,centrocytes, and centroblasts.Mitotic activity and tingible body macrophages are noted within the germinal centers. The nodal capsule is intact and extranodal extension is not present.
      • Immunohistochemical study revelas Bcl-2: focal negative in germinalcenter, cycline-D1: negative, CD10: neagtive in perigerminal
    • 2020-05-11 Nasopharyngoscopy
      • left neck mass
  • consultation
    • 2022-12-17 Thoracic Surgery
      • Q
        • For insertion chest tube.
        • Under sono- and CT-guiding, drainage of left pleural effusion was performed smoothly (8 Fr. pig-tail catheter) and some yellowish fluid was obtained on 20221216.
        • Now obstruction, so we need help insertion chest tube.
      • A
        • I have visited the patient and reviewed the images. Complicated effusion pending empyema was impressed. VATS (Video-assisted Thoracoscopic Surgery) decortication will be indicated. I have explained the current condition with her family. I will arrange operation as soon as possible. Thanks for your consultation!! (Decortication is a type of surgical procedure performed to remove a fibrous tissue that has abnormally formed on the surface of the lung, chest wall or diaphragm.)
    • 2020-09-23 Dermatology
      • Q
        • However vesicles on left waist for one week and pain sensation was noted. we need your expertise for further management, thanks
      • A
        • Skin finding: some erythematous papules and macules and patches with excoriations on face, trunk and 4 limbs
        • Imp: eczema, r/o chichenpox (low probability)
        • Plan:
          • xyzal 1# HS
          • mycomb cream BID topical used for face, trunk and 4 limbs
    • 2020-05-08 ENT
      • Q
        • This 61 year old female is a case of H/T for 6 years regular medication control.
        • She complained left lower neck mass for one month and went to TaoYuan Land Seed Hospital for help. CT showed left neck mass, suspected lymphoma (3.53.5cm fixed to spine r/o neuroma and one lymph node above it around 11cm). Sono guide biopsy done on 2020/04/28 which revealed atypical lymphoid hyperplasia. Owing to personal reason, she came to our hospital for second opinion and was admitted for further management on 2020/05/07.
        • Deaf and mutism
        • we need your expertise for biopsy of left lower neck, thanks
      • A
        • We will arrange tumor excision next week

700541887

221216

  • diagnosis - 20221215 admission note
    • Malignant neoplasm of transverse colon
    • T-colon CA, pT3N1a cM0, stage IIIB, s/p Op
  • past history
    • The patient had no systemic diseases, including CNS,、CV, and infection
    • history of operation:
      • Uterine myoma s/p myomectomy (2014)
      • Left adrenal tumor s/p op (2017),
      • Thyroid benign nodule s/p bil. thyroidectomy (2020), taking thyroid and hypertension drugs
      • Internal hemorrhoid s/p Ligation (2021/12/21, 2022/01/18)
  • family history
    • Her elder sister was diagnosed of endometrial cancer
    • No members of the family with diabetes.
  • exam finding
    • 2022-09-30 CT - chest
      • Indication: colon cancer S/P op A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • One ground glass nodule at right lower lobe up to 1.69cm in largest dimension is found. A daughter nodule up to 0.63cm is also found. The lesions are more solid as compared with previous CT on 2022-09-08, infectious process is considered.
          • S/p port-A placement with its tip at Superior vena cava.
          • Small lymph nodes are found at left axillary region.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Low density lesion at S2 about 1.71cm in largest dimension is found. Simple cyst is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • The liver, pancreas, both kidneys and adrenals are intact.
      • Imp: One ground glass nodule at right lower lobe up to 1.69cm in largest dimension is found. A daughter nodule up to 0.63cm is also found. the lesions are more solid as compared with previous CT on 2022-09-08, infectious process is considered.
    • 2022-09-08 CT - abdomen
      • History and indication:
        • Adenocarcinoma of esophagogastric junction status post laparotomy partial gastrectomy, thoracostomy partial esophacectomy with gastric tube reconstruction and feeding jejunostomy on 2022/07/18, pT3N2M0 stage IIIB
      • With and without-contrast CT of abdomen-pelvis revealed:
        • S/P left adrenectomy.
        • Wall thickening of colon at splenic flexure of colon.
        • Wall thickening of EG junction.
        • A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
        • Liver and renal cysts (up to 1.6cm).
        • A calcified spot (5.7mm) at pancreatic body.
        • Normal appearance of spleen, pancreas.
        • Normal appearance of gallbladder. Bile sludge in CBD.
        • Intact bony structures.
        • No ascites, nor enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • Atherosclerosis of the aorta, coronary and iliac arteries.
      • IMP:
        • S/P left adrenectomy.
        • Wall thickening of colon at splenic flexure of colon.
        • Wall thickening of EG junction.
        • A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
    • 2022-07-19 CXR
      • Atherosclerotic change of aortic arch
    • 2022-07-01 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver cyst, S3
        • Renal cyst, right
        • suspicious, angiomyolipoma of right kidney
      • Suggestion
        • semi-annual ultrasound follow up.
    • 2022-04-15 Patho - colon segmental resection for tumor
      • Diagnosis
        • Large intestine, transverse, laparoscopic left segmental colectomy — Adenocarcinoma, moderately differentiated
        • Omentum, partial omentectomy — Negative for malignancy
        • Resection margins: free
        • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (1/14)
        • Lymph node, IMA / SMA, dissection —- Not received
        • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1a(if cM0)
      • Microscopic Description
        • Histologic Type: Adenocarcinoma
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
        • Margins
          • Proximal margin: Uninvolved
          • Distal margin: Uninvolved
          • Radial or Mesenteric Margin: very close, impending perforation, Distance of tumor from margin: < 0.1 mm
        • Lymphovascular Invasion: Present
        • Perineural Invasion: Present
        • Tumor Budding: Low score (0-4)
        • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
        • Tumor Deposits: Not identified
        • Regional Lymph Nodes:
          • Number of Lymph Nodes Involved/Examined: 1/14; Extranodal involvement: Not identified
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply): absent
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN1: One to three regional lymph nodes are positive (tumor in lymph nodes measuring >=0.2 mm), or any number of tumor deposits are present and all identifiable lymph nodes are negative
          • Distant Metastasis (pM): if cM0
        • Additional Pathologic Findings (select all that apply): None identified
    • 2022-03-25 CT - abdomen, pelvis
      • Findings:
        • There is asymmetrical wall thickening of the distal transverse colon that is c/w adenocarcinoma.
          • In addition, there are five enlarged nodes in the adjacent mesocolon that may be metastatic nodes.
        • There are two poor enhancing lesion 4 mm in S6 and 6 mm in S4 of the liver that may be cyst. Please correlate with sonography. A hepatic cyst measuring 1.5 cm in S3 is noted.
        • There is no focal lesion in both lung and mediastinum.
        • There are several renal cysts on both kidney and the largest one measuring 1.9 cm in size at right middle pole.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3 (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIB (Stage_value)
    • 2022-03-21 Patho - colon biopsy
      • Colon, 40 cm from anal verge, biopsy (B) — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • 2022-03-21 Colonoscopy
      • Diagnosis
        • Suspect colon cancer, probable distal transverse colon, s/p biopsy, tatto and clipping for localization
        • Colon polyps s/p biopsy removal
        • Internal hemorrhoid
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2021-12-27 Gynecologic ultrasonography
      • suspected uterine myoma
  • surgical operation
    • 2022-04-14 Laparoscopic left segmental colectomy
      • A 1.5cm depressed tumor lesion is located at distal T-colon
      • After mobilization of splenic and hepatic frexure of colon, segmental resection of T-colon was carried out smoothly. Blood loss was about 30ml.
    • 2022-01-18 Occlusion of Hemorrhoidal Plexus, Open Approach
    • 2021-12-21 Occlusion of Hemorrhoidal Plexus, Open Approach
    • 2020-09-15 Bil. thyroidectomy + neck lymph node resection
      • Hard, ill-defined tumor mass over L’T thyroid gland without extrathyroid extension noted ( frozen section: follicular neoplasm)
      • Several enlarged pre-trachea LNs also noted
    • 2017-11-24 Adrenalectomy
  • chemoimmunotherapy
    • 2022-12-15 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5140mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-11-18 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5160mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-11-04 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5180mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-10-19 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5150mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-10-19 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5140mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-09-07 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5110mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5090mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-08-09 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5090mg 46hr
    • 2022-07-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5060mg 46hr
    • 2022-07-04 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-06-20 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-06-01 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

700946496

221214

{Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2(-), stage IIA s/p MRM on 2022-05-13}

  • diagnosis - 2022-11-22 discharge note
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T(Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles, (Taxotere 60mg/m2) on 2022/09/07~
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Gout, unspecified
  • past history
    • Hypertension for >10 years, under medical control in Cathay General Hospital
    • Dyslipidemia for about 3 years under medical control    
  • exam finding
    • 2022-12-06 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 22) / 116 = 81.03%
        • LVEF (%) = 81
        • M-mode (Teichholz) 65
      • Normal LV systolic function with normal wall motion.
      • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2
      • Normal RV systolic function.
      • Mild to moderate MR; mild TR; aortic valve sclerosis with no AS and AR.
    • 2022-12-05 24Hr Holter ECG
      • Baseline was sinus rhythm
      • Rare isolated VPCs
      • Rare isolated APCs
      • 1 episode of short-run AT, 4 beats
      • No long pause
    • 2022-11-14 Patho - gallbladder (benign lesion)
      • Gallbladder,laparoscopic cholecystectomy — acute cholecystitis
      • The specimen submitted is a gallbladder, in fixed state. The gallbladder measures 6x 3.4x 1.1 cm in size. The serosa is congested and smooth. On opening, the mucosa is eroded. No ulceration is seen. The wall is elastic measuring up to 0.4 cm in thickness. The cystic duct measures 0.3 cm in length and is not remarkable. No gallstone is submitted. Representative sections are taken.
      • Microscopically, it shows chronic cholecystitis with congestion, submucosal fibrosis,and mixed inflammatory infiltrate with Rokitansky-Aschoff sinus formation.
    • 2022-10-28 Patho - stomach biopsy
      • Stomach, PW site of antrum, biopsy — erosion with Helicobacter infection
      • The specimen submitted consists of 3 tissue fragments measuring up to 0.1x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
      • Microscopically, it shows erosion with loss of superficial mucosal epithelium. Mild Helicobacter-like bacilli are seen.
    • 2022-10-27 Panendoscopy
      • Diagnosis
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis, s/p CLO test
        • Gastric shallow ulcers and erosions, antrum
        • Gastric ulcer scar, PW site of antrum, s/p biopsy
      • Suggestion
        • Pursue CLO test and biopsy result; EGD F/U if clinincally needed
        • oral PPI use
    • 2022-10-24 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • 2022-10-21 CT - abdomen
      • History: Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T (Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles
        • MD CT (Revolution) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • S/P Mastectomy, left.
          • There is a cystic-like lesion in the subcutaneous fat layer of left lower chest wall. please correlate with clinical condition.
        • There is no focal lesion in both lung.
          • There are few enlarged nodes in paratracheal space.
          • Follow up is indicated.
        • Left lobe thyroid shows enlarged in size and a lobulated poor enhancing lesion that may be nodular goiter.
          • Please correlate with sonography.
        • The gallbladder shows mild wall thickening but no evidence of calcified stone or distension.
          • A renal cyst measuring 2.5 cm in right middle pole is noted.
        • There are several ovoid-shaped enlarged lymph nodes in the hepatoduodenal ligament that may be benign reactive nodes.
          • Follow up is indicated.
        • There is no focal abnormality in the liver, biliary system, pancreas, spleen & left kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P Mastectomy, left.
        • There is a cystic-like lesion in the subcutaneous fat layer of left lower chest wall. please correlate with clinical condition.
    • 2022-10-21 SONO - abdomen
      • Diagnosis
        • Fatty liver,mild
        • Suspected fatty infiltration of pancreas
        • Propable GB stone with cholecystopathy
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • 2022-08-15 Patho - soft tissue nontumor/mass/lipoma/debridement
      • Skin and soft tissue, left chest wall wound, debridement — acute inflammation.
    • 2022-07-28 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • 2022-07-07 Foot Bilat
      • fracture at the base of the right 5th metatarsal bone
    • 2022-07-06 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • 2022-06-16 2D transthoracic echocardiography
        1. Adequate LV systolic function with normal resting wall motion
        1. Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
        1. Trivial MR and trivial TR
        1. Preserved RV systolic function
        1. Minimal pericardiac effusion
    • 2022-05-16 Patho - breast mastectomy with regional lymph nodes
      • Diagnosis
        • Breast, left, modified radical mastectomy (S2022-8352A) —- Invasive carcinoma. Micro-papillary type.
        • Resection margin: free
        • Lymph node, left, sentinel lymph node biopsy with frozen section (F2022-228FS) — metastatic carcinoma (2/2)
        • Lymph node, left, axilla lymph node dissection (S2022-8352B) — Free (0/22)
        • pT2 pN1a (if cM0); anatomic stage: IIB, at least; pathology prognostic stage: IIA, at least.
      • Microscopic Description
        • For Invasive Carcinoma
          • Histologic type: Invasive carcinoma, micropapillary type
          • Size of invasive carcinoma (mm): 31 x 26 x 25 mm
          • Histologic grade (Nottingham histologic score): grade III (score 8,9)
          • Extent of tumor (required only if the structures are present and involved)
            • Skin involvement: Absent
            • Chest wall invasion deeper than pectoralis muscle: no tissue submitted
        • For Ductal Carcinoma In Situ: not present
        • Margins:
          • Negative, Closest margin (26 mm from deep margin)
        • Nodal status: Positive = 2/2 SLN and 0/22 left axilary LN
          • No. examined: 24
          • No. macrometastases (>2 mm): 2
          • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
          • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy - no neoadjuvant therapy
        • Immunohistochemical Study: result of biopsy specimen: S2022-07648
          • ER(+, strong intensity, >95%), PR(+, strong intensity, 70%), Her2/Neu: (-, score= 0/1+), Ki-67 index: 5%.
    • 2022-05-13 Frozen resection
      • Preliminary diagnosis: SLN left - metstatic carcinoma (2/2)
    • 2022-05-13 Lymphoscintigraphy
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
      • Impression: Probably a sentinel lymph node at the left axillary region.
    • 2022-05-12 Tc-99m MDP whole body bone scan
      • Increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
      • Increased activity in the mandible. Dental problem may show this picture.
      • A hot spot in the left parietal area of the skull and some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and knees, compatible with benign joint lesions.
    • 2022-05-11 2D transthoracic echocardiography
      • Dilated LA
    • 2022-05-11 Lung Flow-Volume Curve
      • mild restrictive impairment
    • 2022-05-11 SONO - abdomen
      • renal cyst, left
    • 2022-05-02 Patho - breast biopsy
      • Diagnosis
        • Breast, left, sono-guide biopsy — invasive carcinoma
      • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells arranged in single-file or cord-like architecture and infiltrative growth pattern, and stromal fibrosis. The tumor cell shows round to oval nuclei, nuclear hyperchromasia, plemorphism,and dot-like nucleoli.
      • IHC stain — ER(+, strong intensity, >95%), PR(+, strong intensity, 70%), Her2/Neu: (-, 0/1+), Ki-67 index: 5%, E-cadherin(+).
    • 2022-05-02 SONO - breast
      • core needle biopsy
      • Left breast tumors, 2’ region and subareolar region, suspected malignancy, suggest biopsy.
      • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
    • 2022-03-21 Nerve Conduction Electromyography
      • Findings
        • normal motor DLs, CMAP amplitudes and NCVs of bil. median and ulnar n. Conduction slowing of bil. ulnar n. at elbow.
        • normal sensory DLs, lower SNAP amplitudes and normal NCVs of bil. ulnar n.
        • the F-wave latencies of bil. median and ulnar n. were normal.
      • Conclusion: bil. ulnar n. lesion at elbow
    • 2021-12-06 Neurosonology
        1. Minimal atherosclerosis in right CCA bifurcation.
        1. Adequate total VA flow volume (88 ml/min).
        1. Increased RI in right CCA, bilateral ICA and bilateral VA, indicating distal stenosis.
    • 2021-02-14 CXR
      • Normal heart size.
      • Tortous aorta with calcification is noted.
      • There is no evidence of destructive bone lesion.
      • Scoliotic alignment of the thoracolumbar spine is noted.
      • The lung fields are clear.
      • Clear bilateral costophrenic angle is noticed.
      • Patent airway is found.
      • Suggest clinical correlation
    • 2021-02-14 ECG
      • Normal sinus rhythm
      • Nonspecific ST abnormality
    • 2018-12-10 Flow-volume curve
      • FVC 78%, VC redueced.
    • 2017-09-28 Neck soft tissue
      • mild anterior and posterior spur formation in the lower C-spine
      • moderate decreased disc spaces in the C5/6 and C6/7 discs
    • 2017-01-25 CT - abdomen
      • Findings
        • Diverticulosis of cecum and ascending colon. Perifocal fat stranding of proximal A-colon
        • Bilateral renal cysts.
      • Impression:
        • Acute diverticulitis of A-colon
  • consultation
    • 2022-10-28 General and Gastrointestinal Surgery
      • Q
        • This 76-year-old woman patient is a case of Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T(Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles. This time, for right chest pain radiation back pain developed. Abdominal echo on 2022/10/21 showed fatty liver, mild, suspected fatty infiltration of pancreas and propable GB stone with cholecystopathy. Lab deta with TBI showed increased (6.61–>2.71–>1.28–>1.27mg/dL). Now, for evaluate OP of GB stone. Thank you.
      • A
        • S: Due to suspected GB stones with acute cholecystitis, surgical evaluation is consulted.
        • O:
          • vital signs: stable, no fever
          • abdomen: soft, ovoid, decrease bowel sound, mild RUQ & R’t back tenderness, no Murphy’s sign
          • lab data: see chart
          • CT: GB wall thickness
        • A: Acute acalculous cholecystitis
        • P: NPO, adequate hydration, antibiotics treatment, and closely observation is suggested.
    • 2022-05-11 Rehabilitation
      • This 76 year-old women, she has left breast cancer withleft simple mastectomy + SLNB on 2022/05/13. We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
      • Premorbid functional status
        • Walk ID, ADLs ID.
      • Physical examination
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Bilateral shoulders PROM:
          • right shoulder pain . Right forward flexion PROM 0-160 with pain. ER 0-60 pain+
          • left shoulder no limitation.
        • Hand and arm circumference (R/L,cm):
          • Elbow joint above 5cm 35/34
          • Elbow joint below 5cm 27/27 rt handed
      • Imp
        • left breast cancer
        • partial mastectomy + SLNB 5/13
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications
  • surgical operation
    • 2022-08-12 Excision of skin or subcutaneous tumor within 2cm
    • 2022-05-13 Simple mastectomy sentinel lymph node biopsy
      • Surgery
        • Left breast MRM (Modified Radical Mastectomy)
      • Finding
        • left breast tumors x2
        • size: 1cm
        • location: retroalreolar
        • size: 2cm
        • location: 2’/2.5cm
  • radiotherapy
    • 2022-05-19 OPD
      • Plan:
        • Adjuvant chemotherapy followed by radiotherapy is indicated for this patient with the following indicators: stage pT2N1a (cM0)
        • Goal: curative
        • Treatment target and volume: left chest wall to SCF
        • Technique: IMRT
        • Preliminary planning dose: 5000cGy/25 fractions of the left chest wall to SCF
  • chemoimmunotherapy
    • 2022-12-13 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-11-21 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-09-26 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-09-06 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-08-17 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
    • 2022-07-28 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
    • 2022-07-06 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
    • 2022-06-16 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3

[note]

  • Breast Cancer NCCN Evidence Blocks, version 2.2022, 2021-12-20
    • BCS (breast-conserving surgery) not possible (p20)
      • Mastectomy and surgical axillary staging + reconstruction (optional)
        • Adjuvant systemic therapy + post-mastectomy adjuvant RT
          • cN+ and ypN0: Strongly consider RT to the chest wall and comprehensive RNI (regional nodal irradiation) with inclusion of any portion of the undissected axilla at risk.
          • Any ypN+: RT is indicated to the chest wall + comprehensive RNI with inclusion of any portion of the undissected axilla at risk.
        • Adjuvant systemic therapy without adjuvant RT for any cN0,ypN0 if axilla was assessed by SLNB or axillary node dissection
    • Preoperative/Adjuvant therapy regimens (p55)
      • HER2-Negative
        • Preferred Regimens:
          • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
          • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
          • TC (docetaxel and cyclophosphamide)
          • Olaparib, if germline BRCA1/2 mutations
          • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
          • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
        • Useful in Certain Circumstances:
          • Dose-dense AC (doxorubicin/cyclophosphamide)
          • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
          • CMF (cyclophosphamide/methotrexate/fluorouracil)
          • AC followed by weekly paclitaxel
          • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
        • Other Recommended Regimens:
          • AC followed by docetaxel every 3 weeks
          • EC (epirubicin/cyclophosphamide)
          • TAC (docetaxel/doxorubicin/cyclophosphamide)
          • Select patients with TNBC: -Paclitaxel + carboplatin (various schedules) -Docetaxel + carboplatin (preoperative setting only)

==========

2022-12-14

  • The underlying conditions in this patient include: essential (primary) hypertension, hyperlipidemia, gout.
  • 2D transthoracic echocardiography (2022-12-06) revealed: LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2; Mild to moderate MR; mild TR; aortic valve sclerosis.
  • Available records of blood uric acid levels showed no exceeding the upper limit of normal.
    • 2022-10-22 Uric Acid 3.9 mg/dL
    • 2022-07-19 Uric Acid 5.1 mg/dL
  • Gout patients with established cardiovascular (CV) disease treated with febuxostat had a higher rate of CV death compared to those treated with allopurinol in a CV outcomes study. Consider the risks and benefits of febuxostat when deciding to prescribe or continue patients on febuxostat. Febuxostat is recommended only used in patients who have an inadequate response to a maximally titrated dose of allopurinol, who are intolerant to allopurinol, or for whom treatment with allopurinol is not advisable.
  • As an alternative to xanthine oxidase inhibitors, the uric aicd resorption suppressor benzbromarone might be another candidate for treating gout.

2022-09-07

  • A decline in renal function has been observed. Time series lab log:
    • Date // Creatinine // eGFR
    • 2022-09-06 1.22 45.55 (CrCl ~ 40 mL/min)
    • 2022-08-30 1.19 46.87
    • 2022-08-17 0.91 63.88
    • 2022-08-09 0.77 77.46
  • The kidneys excrete little docetaxel (~6%), therefore, the need for docetaxel dosage adjustments for renal dysfunction is unlikely.
  • Allegra (fexofenadine 60mg/tab) for GFR 10 to 50 mL/min: Recommended dose every 12 to 24 hours. A possible change is from BID to QD.
  • Promeran (metoclopramide 3.84mg/tab) for CrCl >10 to 60 mL/min: Administer ~50% of usual total daily dose. A change from TIDAC to BIDAC might be considered.
  • During this hospitalization, the blood pressure was well controlled. The laboratory data related to hyperlipidemia have not been updated since October 2021. A number of tests might be ordered, e.g., TC, LDL-C, Non-HDL-C, ApoB, TG, HDL-C, and ApoA-1.

2022-08-18

  • There was no evidence of intolerance.
  • The TPR and blood pressure were stable during this hospitalization and the lab results for 2022-08-17 were generally normal.
  • Underlying cardiovascular conditions are managed with Sevikar (amlodipine + olmesartan), Concor (bisoprolol) and Crestor (rosuvastatin) without issues.

2022-07-07

  • Since mid-June 2022, the patient has been receiving doxorubicin and cyclophosphamide.
  • An optional addition might be tamoxifen or an aromatase inhibitor. (A Comparison of Letrozole and Tamoxifen in Postmenopausal Women with Early Breast Cancer. https://www.nejm.org/doi/pdf/10.1056/NEJMoa052258 )

701362191

221214

  • diagnosis
    • 2022-07-18 discharge note
      • Malignant neoplasm of pyloric antrum
      • Gastric cancer s/p lap radical Subtotal gastrectomy with D2 dissection on 2022/03/07, pT4aN1M0, stage IIIA s/p chemotherapy with FOLFOX (from 2022/04/12~2022/06/21 for 6 cycles)
      • Type 2 diabetes mellitus without complications
  • exam findings
    • 2022-10-09 Wrist RT
      • Normal bone alignment
      • mild decreased right wrist joint space
    • 2022-08-10 SONO - abdomen
      • Normal sonographic study of the hepatobiliary system.
    • 2022-07-01 CT - abdomen
      • History: epigastric pain
        • UGI scope revealed gastric ca at lower body.
        • 20220223 CT:gastric cancer, cT3N0M0, cSTAGE:IIB
        • 20220308 subtotal gastrectomy PATHO: pT4aN1(if cM0); pstage IIIA
      • Findings:
        • S/P subtotal gastrectomy
        • S/P IUD retention within the endometrial cavity.
      • Impression:
        • S/P subtotal gastrectomy.
        • There is no evidence of tumor recurrence.
    • 2022-03-08 Patho - stomach subtotal/total (tumor)
      • Diagnosis:
        • Stomach, middle body, lesser curvature, laparoscpic subtotal gastrectomy — Poorly cohesive carcinoma with signet-ring cell differentiation
        • Cut-ends, proximal and distal, laparoscpic subtotal gastrectomy — Free
        • Lymph node, LN 1, dissection — Negative for malignancy (0/1)
        • Lymph node, LN 3, dissection — Metastatic carcinoma (2/8)
        • Lymph node, LN 4, dissection — Negative for malignancy (0/9)
        • Lymph node, LN 5, dissection — Negative for malignancy (0/3)
        • Lymph node, LN 6, dissection — Negative for malignancy (0/4)
        • Lymph node, LN 7,8,9,11p, 12a, dissection — Negative for malignancy (0/18)
        • Lymph node, LN14V, dissection — Negative for malignancy (0/1)
        • AJCC 8th edition Pathology stage: pT4aN1(if cM0); AJCC stage IIIA
      • Microscopic Description:
        • Histologic Type — Poorly cohesive carcinoma with signet-ring cell differentiation
        • Histologic Grade — Poorly differentiated
        • Tumor Extension — Tumor invades the serosa (visceral peritoneum)
        • Margins
          • Proximal margin: uninvolved by invasive carcinoma
          • Distal margin: uninvolved by invasive carcinoma
          • Radial margin: uninvolved by invasive carcinoma
        • Lymphovascular Invasion: present
        • Perineural Invasion: present
        • Regional Lymph Nodes — Number of lymph nodes examined: positive (2/44)
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply)
            • m (multiple primary tumors) r (recurrent) y (posttreatment)
            • Primary Tumor (pT) — pT4a: Tumor invades the serosa (visceral peritoneum)
            • Regional Lymph Nodes (pN) — pN1: Metastasis in one or two regional lymph nodes
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case) — N/A
          • IHC stain— CK(+), CK20(focal+), CK7(+), CDX-2(+)
    • 2022-03-04 Patho - stomach biopsy
      • Tumor, gastric angle, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by linear or individual tumor cells infiltrating in stroma.
      • Immunohistochemistry of CK(+) and Her2 (-, Dako score 0) for tumor cell.
      • Besides, colony of Helicobacter Pylori is not present in the submitted specimen.
    • 2022-02-23 CT - abdomen, gastric filling with water
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T3 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IIB(Stage_value)
  • surgical operation
    • 2022-03-07 laparoscpe subtotal gastrectomy with LN D2 dissection
      • Finding
        • 3cm ulcerative mass at middle body lesser curvature with serosa involve
        • regional LN enlarge at station 3
        • peritoneal seeding (-)
        • ascite (-)
        • cT4aN1M0
  • chemoimmunotherapy
    • 2022-12-13 - oxaliplatin 85mg/m2 165mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-11-24 - oxaliplatin 85mg/m2 165mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-11-09 - oxaliplatin 75mg/m2 145mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-10-17 - oxaliplatin 65mg/m2 120mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr # Allergy with whole body skin redness rash with itch after chemotherapy with Oxalip
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-09-13 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
    • 2022-08-24 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
      • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
    • 2022-07-18 - leucovorin 20mg/m2 40mg 10min D1 + fluorouracil 400mg/m2 600mg 10min D1 (CCRT)
      • premed - dexamethasone 4mg + metoclopramide 10mg D1
    • 2022-07-12 - leucovorin 20mg/m2 40mg 10min D1-4 + fluorouracil 400mg/m2 600mg 10min D1-D4 (CCRT)
      • premed - dexamethasone 4mg + metoclopramide 10mg D1-D4
    • 2022-06-21 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
      • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
    • 2022-06-07 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-05-24 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-05-10 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-04-26 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-04-12 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr

==========

2022-12-14

  • It has not been observed that there is an allergy resulting in a skin rash or itching after the addition of diphenhydramine and famodidine as the premedication since Oct 2022.
  • During this hospital stay, the FS blood sugar levels were around 200 mg/dL. The available blood sugar records indicate that the patient’s blood sugar levels almost always exceed the upper limit of normal for the past months. If no imaging is scheduled that requires iodinated contrast, metformin 500mg BID is recommended since her kidneys do not exhibit any insufficiency.

2022-11-25

  • Perhaps due to a lack of authorization from the patient, the recent 3-month prescription list is not available from PharmaCloud at present.
  • According to the admission note, the patient regularly takes both Amepiride (glimepiride) and meformin to control her type 2 DM.
  • For the renal hyperfiltration (2022-11-23 eGFR 133) was still noted and her preprandial blood sugar level is still high (173mg/dL 2022-11-25 07:02) under current single antidiabetic agent Amepiride (glimepiride), it is recommended that metformin be added to her active prescription as a patient-carried item if no imaging scheduled.

2022-11-10

  • A preprandial blood sugar level of 198mg/dL was recorded on 2022-11-10 morning.
  • The renal hyperfiltration (2022-11-03 eGFR 125) driven by increased glomerular filtration pressure and by glucose diuresis can affect renal O2 consumption that unleashes detrimental sympathetic activation. The sodium-glucose co-transporters inhibitors (SGLTi) can rebalance the reabsorption of Na+ coupled with glucose and can restore renal O2 demand, diminishing neuroendocrine activation. (ref: The Benefit of Sodium-Glucose Co-Transporter Inhibition in Heart Failure: The Role of the Kidney. Int J Mol Sci. 2022;23(19):11987. Published 2022 Oct 9. doi:10.3390/ijms231911987)
  • There is only one antidiabetic agent Amepiride (glimepiride) in the active prescription. The SGLT2i drugs empagliflozin, dapagliflozin, and canagliflozin are available in stock and could be considered if UTI is unlikely.

2022-10-18

  • This patient has been prescribed Amepiride (glimepiride) for months, which may cause body weight gain, however, her body weight has decreased by more than 15kg during the past seven months (85kg 2022-10-17 <- 101kg 2022-03-06). Is it an intentional diet cuased weight loss or an unintentional weight loss? Did insulin resistance result in body breakdown or poor dietary intake?
  • Pre-breakfast blood sugar level reached 215 mg/dL on 2022-10-18 under metformin and glimepiride. If fasting levels persist over 200 mg/dL for two consecutive days, acarbose, vidagliptin, or dapagliflozin might be added to the current medication list.

700105612

221212

  • exam findings
    • 2022-12-09 CT - brain
      • Indication: confusion
      • Findings
        • brain atrophy with prominent sulci, fissures and dilated ventricles.
        • confluent hypodensity at bilateral periventricular white matter, indicating leukoaraiosis.
        • no acute intracranial hemorrhage.
        • no definite skull lesion.
        • chronic left maxillary sinusitis.
      • Impression:
        • Brain atrophy and leukoaraiosis.
        • Chronic left maxillary sinusitis.
    • 2022-12-09 CXR
      • Cardiomegaly is noted.
      • Osteopenia of the bony structure is noted.
      • Senile fibrotic change is noted at lung fields.
    • 2022-11-04 Water’s view
      • Opacification of left maxillary sinus.
    • 2022-11-04 Nasopharyngoscopy
      • sticky post nasal drip
    • 2022-10-26 CXR
      • S/P coronary artery stent implantation.
      • Enlargement of cardiac silhouette.
    • 2022-02-11 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (82.2 - 29.0) / 82.2 = 64.72%
        • M-mode (Teichholz) = 64.7
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial mitral and tricuspid regurgitation
      • Impaired LV relaxation
      • Mildly thick IVS and LVPW
    • 2022-02-09 CXR
      • Patchy opacity projecting in the right lower mediastinum shows stationary.
      • S/P coronary artery stent implantation.
    • 2022-02-09 ECG
      • Sinus rhythm with Premature supraventricular complexes and with occasional Premature ventricular complexes
    • 2022-09-23 CXR
      • Patchy opacity projecting in the right lower mediastinum is suspected. Follow up is indicated.
      • S/P coronary artery stent implantation.
    • 2021-09-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (87.7 - 36.2) / 87.7 = 58.72%
        • M-mode (Teichholz) = 58.7
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with trivial AR, mild MR, TR and PR
      • No regional wall motion abnormalities
    • 2021-08-26 Patho - gingival/oral mucosa biopsy
      • Bone, left maxilla, excisional biopsy — Dead bone with acute and chronic inflammation
      • Section shows squamous mucosa and dead bone with granulation tissue, fibrosis, and acute and chronic inflammation.
      • The immunohistochemical stain of CD138 shows no aggregation of plasma cells in bone.
    • 2020-12-07 CXR
      • Patchy opacity projecting in the right lower mediastinum is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
      • S/P coronary artery stent implantation.
    • 2020-12-07 ECG
      • Sinus rhythm with Premature atrial complexes
      • Increased R/S ratio in V1, consider early transition or posterior infarct
    • 2020-11-03 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Myeloma.
      • IHC stains: CD138 : 10-15%, lambda light chain > kappa light chain. IgA: 10-15%, IgG: <5%.
      • Section shows piece(s) of bone marrow with 40-50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are a few plasmacytoid cells present.
    • 2020-08-14 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Negative for malignacy (CD138+ plasma cell: < 5%)
      • Microscopically, it shows 3 % of cellularity, 1:1 of M:E ratio, presece of trilinegae cellular component and ocassional megakaryocytes.
      • Immunohistochemical stain reveals CD138(< 5%), CD71(+), CD20(-), CD117(-), Kappa(-), MPO(focal+), CD117(-).
      • NOTE: Clincal correlation is essential.
    • 2020-06-24 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
        • M-mode (Teichholz) = 74
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis; degenerative changes of mitral valve with trivial MR.
      • Dilated proximal ascending aorta (35mm); mild aortic root calcification.
    • 2020-04-10 Patho - bone marrow biopsy
      • Bone marrow, iliac, history of myeloma (S2018-2795), biopsy — Compaible with replased of myeloma.
      • IHC stains: CD138: 10-15% of the nucleated cells, lambda > kappa, approximately 3:1.
      • Section shows one piece of bone marrow with 30 % cellularity and M:E ratio of approximately 3:1. There is aprroxomately 10-15% of the plasmcytoid cells demonstrated by IHC stain of CD138. lambda > kappa, approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
    • 2020-03-20 Patho - breast biopsy
      • Breast, right, sono-guided biopsy — Gynecomastia
    • 2020-03-20 SONO - breast
      • Subareolar duct development, both side, gynecomastia should be considered. Suggest clinical correlation.
    • 2019-03-01 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 36) / 105 = 65.71%
        • M-mode (Teichholz) = 65
      • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild AV sclerosis; mild MR; mild PR.
    • 2018-10-25 transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 30.3) / 102 = 70.29%
        • M-mode (Teichholz) = 70.3
      • Normal chamber size
      • Adequate LV and RV performance
      • Possibly impaired LV relaxation
      • AV sclerosis with trivial AR ; mild MR, TR and PR
      • No regional wall motion abnormalities
    • 2018-09-07 Surgical pathology Level IV
      • Bone marrow, iliac, biopsy — see description.
      • Section shows one piece of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
      • IHC stain shows approximately 10 % of CD138 (+) plasmacytoid cells with slightly more kappa than lambda light chain stain, suggestive of few residual neoplastic cells. Additional CD34 (+) <1%, CK (-).
    • 2018-04-03 MRI - T-spine
      • Indication: A case of myeloma, T, L spine survey, for chest pain
      • Findings:
        • Moderate degree of old compression fracture of T3 vertebral body.
        • Abnormal enhanced lesions in T3, T4, T5, T7, T8 T12, and L1 vertebrae (as hypointense on T1WI).
        • Mild degree of compression fracture of T9 vertebral body (hypointense on T1WI, hyperintense on STIR images), with abnormal enhancement.
        • Marginal spurs of multiple vertebral bodies.
        • Mild thickening of ligamentum flavum at T10-T11 level..
        • The visualizedl spinal cord shows normal size and signal intensity. There is no extrinsic compression of the cord.
      • Impression:
        • multiple myeloma with T4 and T9 compression fracture and small enhancing
        • lesions in multiple vertebrae.
    • 2018-03-19 transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 28) / 111 = 74.77%
        • M-mode (Teichholz) = 74
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, LV diastolic dysfunction, Gr 1
      • Mild MR, mild TR
      • Preserved RV systolic function
    • 2018-03-19 ECG
      • Sinus rhythm with Premature atrial complexes
    • 2018-02-20 Surgical pathology Level IV
      • Bone marrow, biopsy — Plasma cell myeloma
      • The sections show slightly hypercellular marrow (50%). Sheets of mature plasma cells with numerous Russell bodies in interstitium, account for 50% nucleated cells in CD138 immunostain. These plasma cells also reveal kappa light chain restriction and negative for lambda light chain.
    • 2017-04-17 CT - heart CTA
      • History:
        • 20110128
          • Admitted due to exertional dyspnea and palpitation, cardiac catheterlization was perforemd smoothly and reveaeld CAD, LAD. middle, right hand cath wound clear, still irregular heart rate and DOE, keep medication therapy.
          • History of abnormal LFT told in Cathay General Hospital even with lipitor for 10 mg ∕QD
        • 200812
          • Referred from chief Lin, hx of Palpitation, and short run of Af; palpitation when emotional upset. Palpitation and chest pain for 17 years.
          • Holter ECG in Cathay General Hospital showed occasional APC and VPCs with 4minutes of short run Af with no symptoms even with lipitor for 10 mg ∕QD
      • Nonenhanced ECG-gated CT for calcium scoring and enhanced spiral CT of heart and coronary arteries were obtained using 256-slice multidetector row CT scanner (iCT philips) showed:
        • Calcification of the coronary arteries (total calcium score=643, LMA=7.33, LAD=514.48, LCX=77.31, RCA=43.87)
        • Left main coronary artery: Patent
        • Left anterior descending coronary artery: calcified plaques in S6, S7, and S8, with severe stenosis in S7 and S8.
        • Visible diagonal branches: Patent
        • Left circumflex coronary artery: Patent
        • Visible obtuse marginal branches: Patent
        • Right coronary artery: Patent
        • Posterolateral and posterior descending branches: Patent
        • Pericardium : Unremarkable
        • Cardiac structure and morphology: Normal cardiac chamber size
        • Lungs: Unremarkable
        • Mediastinum and hilars: No mass lesion
        • Visible abdominal contents: Unremarkable
      • Impression
        • Total calcium score = 643, indicating extensive atherosclerotic plaque burden.
        • Atherosclerosis major coronary arteries with significant stenosis in LAD, S7 and S8.
        • No lung nodule.
    • 2017-04-12 24hrs Holtor’s scan
      • Sinus rhythm
      • Occasional isolated apcs
      • Rare apc couplets
      • A few isolated vpcs
      • No long pause
      • No significant tachyarrhythmia
    • 2017-03-06 MRI - L-spine
      • Mild cervical spondylosis.
      • Disc bulge with mild stenotic lateral recesses, L3-L4,L4-L5.
      • Multilevel degenerative disc disease.
  • consultation
    • 2022-12-12 Family Medicine
      • Q
        • The 76 y/o man has IgA Multiple myeloma, 20180223 proved with bone marrow study. VTD from 20180301, S/P autoPBSCT on 20190306, complicated with HSV-1 genital ulcer infection (20190401). S/P Lenalidomide + dexa. Daraturumab + Velcade + dexa. Kyrolip + dexa. IgA level in progress. Last time, he received chemotherapy as Kyrolip on 2022/11/11. He has poor intake for 3 weeks, just 1 meal a day and lay down all day. He denied take medicine as oral steroid and oral chemotherapy. This time, he has multiple bone pain for 2 weeks and in progress, and yellow snivel around 1 month (his wife not sure), so he was brought to our ED for help. At ED, the lab data showed anemia, mild elevated CRP level and hypokalemia. Due to confusion consciousness, brain CT was arranged at ER and showed 1. Brain atrophy and leukoaraiosis, 2. Chronic left maxillary sinusitis. Under the impression of IgA MM without control and severe bone pain, and malnutrition, so he was admitted on 2022/12/09.
        • Due to disease progression, the patient’s family ask for palliative care. We need your help for further evaluation. Thank you very much.
    • 2022-12-12 Neurology
      • Q
        • Due to confusion consciousness, brain CT was arranged at ER and showed: 1. Brain atrophy and leukoaraiosis, 2. Chronic left maxillary sinusitis. We need your help for further evaluation and treatment suggestion. Thank you very much.
  • surgical operation
    • 20190306 autoPBSCT
  • chemoimmunotherapy
    • 2022-11-11 - Kyprolis (carfilzomib) 70mg/m2 100mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-09-21 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-09-07 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-08-17 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-08-03 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-07-20 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-07-06 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-06-15 - Kyprolis (carfilzomib) 70mg/m2 115mg 1hr
    • 2022-05-25 - Kyprolis (carfilzomib) 70mg/m2 115mg 1hr
    • 2022-05-04 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
    • 2022-04-20 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
    • 2022-04-06 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
    • 2022-03-23 - Kyprolis (carfilzomib) 70mg/m2 118mg 1hr
    • 2022-03-09 - Kyprolis (carfilzomib) 70mg/m2 118mg 1hr
    • 2022-03-02 - Kyprolis (carfilzomib) 50mg/m2 85mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-03-02 - Kyprolis (carfilzomib) 20mg/m2 34mg 1hr
      • premed - diphenhydramine 50mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2021-12-29 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
      • premed - diphenhydramine 50mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2021-12-01 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-11-03 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-10-06 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-09-01 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-08-04 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-07-07 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-06-15 - Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-05-18 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-04-27 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-04-06 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-03-16 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-02-23 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-02-02 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-29 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2021-01-26 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-22 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2021-01-19 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-11 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-04 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2020-12-31 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2020-12-28 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2020-12-21 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2020-12-14 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 7hr
    • 2020-12-11 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2020-12-07 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 7hr
    • 2018-03-19 ~ 2018-11-28 - Velcade (bortezomib) 2.25mg SC (weekly, biweekly, triweekly)
    • 2020-11-13 ~ 2021-07-21 - Xgeva (denosumab) 120mg Q1M SC
    • 2018-04-06 ~ 2019-01-03 - Zobonic (zoledronic acid) 4mg IV (roughly monthly)
    • 2021-08-04 ~ 2022-11-25 - Endoxan (cyclophosphamide) 50mg BID PO
    • 2020-05-15 ~ 2020-10-29 - Revlimid (lenalidomide) 25mg QD PO
    • 2018-03-19 ~ 2020-01-31 - Thado (thalidomide) 50mg HS PO

[assessment]

  • FS blood sugar levels from 2022-12-10 to 2022-12-11 were approximately 300 to 400 mg/dL. If the reading on 2022-12-12 still exceeds 200 mg/dL (regular insulin 8 unit has been prescribed since 2022-12-11), then addition of basal insulin might be considered.

700071716

221209

{NSCLC, not completed}

  • diagnosis - 2022-12-09 discharge note
    • Right upper lobe lung cancer, adenocarcinoma, T2bN1M1b with bone metastasis, ECOG 1
    • Encounter for antineoplastic chemotherapy
    • Encounter for antineoplastic immunotherapy
    • Chronic viral hepatitis B without delta-agent
    • Hypertension
    • paronychia with granulation over toenail
    • Suspect folliculitis with secondary irriation eczema
    • mebomian gland dyusfunction
    • Dry eye
    • Reflux esophagitis LA Classification grade A
  • lab data
    • 2021-10-13 ROS1 FISH not detected
    • 2021-10-08 ROS1 IHC Negative
    • 2021-10-06 EGFR G719X not detected
    • 2021-10-06 EGFR Exon19 del not detected
    • 2021-10-06 EGFR S768I not detected
    • 2021-10-06 EGFR T790M not detected
    • 2021-10-06 EGFR Exon20 ins not detected
    • 2021-10-06 EGFR L858R detected
    • 2021-10-06 EGFR L861Q not detected
    • 2021-10-05 ALK IHC Negative
    • 2021-10-05 PD-L1 (22C3) TPS>=1% and <50%
    • 2021-09-22 Anti-HCV Nonreactive
    • 2021-09-22 Anti-HCV Value 0.05 S/CO
    • 2021-09-22 HBsAg Nonreactive
    • 2021-09-22 HBsAg (Value) 0.35 S/CO
    • 2021-09-22 Anti-HBs 7.64 mIU/mL
  • exam findings
    • 2021-09-22 Patho - lung transbronchial biopsy
      • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated
      • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • consultation
    • 2022-12-06 Dermatology
      • A
        • The patient had sufferred from pronychia with granulation formaiton. several itchy papules over expose area with mild vesicles was noted.
        • Under the impression of paronychia with granulation over toenail. suspected folliculitis with secondary irriation eczema.
        • The following sugeetion:
          • Do cryotherapy at Derma OPD and further wound care with tetracycline onit 1 tube topical bid use.
          • consider Doxycycline 1# bid and allgrea 1# bid po use for 7 days.
          • Ulex cream 1 tube topical bid over itchy papules of the trunk.
    • 2022-12-06 Ophthalmology
      • A
        • S: bilateral eye strain and pain for 2 days
        • O
          • bcva od 0.15(1.0/-2.5) os 0.1(1.0x-2.25)
          • pt 18/18 mmHg
          • pupil: 3mm+/+, 3mm+/+, no rapd
          • MGD
          • conj: np ou
          • K: cl ou
          • ac deep and clear ou
          • lens ns+
          • c/d: 0.5-6 neurorim ok
        • A
          • mebomian gland dyusfunction ou
          • dry eye ou
        • P
          • tear nature 1gtt qid ou
          • if s/s worsen, come back earlier
  • chemoimmunotherapy
    • 2022-12-06 - Opdivo (nivolumab) 100mg 1hr
    • 2022-12-05 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-11-14 - Opdivo (nivolumab) 100mg 1hr
    • 2022-11-10 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-10-09 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-09-27 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-09-06 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-08-16 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-07-26 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-07-05 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-06-14 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-05-24 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-05-03 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-04-12 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-03-22 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-03-01 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-02-08 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-01-11 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-12-21 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-11-30 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2021-11-09 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2021-10-19 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2021-10-07 ~ undergoing - Giotrif (afatinib 30mg) 1# QDAC
    • 2022-09-05 - Xgeva (denosumab) 120mg SC
    • 2022-08-13 - Xgeva (denosumab) 120mg SC
    • 2022-07-15 - Xgeva (denosumab) 120mg SC
    • 2022-06-13 - Xgeva (denosumab) 120mg SC
    • 2022-05-02 - Xgeva (denosumab) 120mg SC
    • 2022-04-08 - Xgeva (denosumab) 120mg SC
    • 2022-03-11 - Xgeva (denosumab) 120mg SC
    • 2022-02-07 - Xgeva (denosumab) 120mg SC
    • 2022-01-07 - Xgeva (denosumab) 120mg SC
    • 2021-12-10 - Xgeva (denosumab) 120mg SC

700191291

221209

  • lab data
    • 2022-04-21 ROS1 IHC
      • The immunostaining of the section slide labeled S2022-03626, using ROS1(SP384) antibody along with a Ventana autostainer system, revealed 1+ cytoplasmic staining, in over 50%, of tumor cells.
    • 2022-03-28 PD-L1 (22C3)
      • Tumor Proportion Score (TPS) assessment: TPS >= 50%
      • Tumor Proportion Score (TPS): 50%
    • 2022-03-21 ROS1 FISH
      • Rearrangement of ROS1 gene is NOT detected.
      • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
    • 2022-03-18 EGFR gene mutation
      • The EGFR mutation testing was for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681, Insertions), 21 (L858R, L861Q) mutations of EGFR gene.
      • A point mutation was detected at exon 21 (L858R) of EGFR gene in this specimen.
    • 2022-03-17 ALK IHC
      • The immunostaining of the section slide labeled S2022-03626, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
    • 2022-03-03 Anti-HCV Nonreactive
    • 2022-03-03 Anti-HCV Value 0.04 S/CO
    • 2022-03-03 HBsAg Nonreactive
    • 2022-03-03 HBsAg (Value) 0.39 S/CO
    • 2022-03-02 Mycoplasma IgM Negative Index
    • 2022-03-02 Mycoplasma IgM Value 0.1 Index
  • exam findings
    • 2022-12-07 Tc-99m MDP whole body bone scan
      • Findings:
        • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
      • Impression:
        • All of above-mentioned bone lesions are old and most of them show stationary or less evident compared with the previous study on 2022-07-13, indicating partial response to current therapy.
        • There is still lung cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
    • 2022-12-06 MRI - brain
      • As compared with prior MRI (2022/07/12), markedly regression of the multiple nodules over bil. cerebellar and cerebral, no obvious edema was found.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Paranasal sinusitis.
    • 2022-12-06 CT - chest
      • Indication: lung cancer restaging
      • Findings: Comparison was made with previous CT dated on 2022/07/12
        • Lungs:
          • normal appearance of RML, RLL, and left lung.
          • residual spiculated RUL tumor with corona radiata (26mm in longest dimension), in comparison with the previous study, the lesion is slightly decreasing in size.
          • Mediastinum and hila: no enlarged LN.
        • Vessels:
          • Aorta: normal caliber of thoracic aorta.
          • Central pulmonary arteries: normal caliber.
          • Heart: normal in size of cardiac chambers.
        • Pleura: minimal residual bilateral effusions.
        • Visible abdominal contents:
          • no abnormal density and size of visible portion of the liver, spleen, both adrenal glands, and pancreas
          • no enlarged lymph node.
        • Visualized bones: destructive lytic or blastic change in visualized bones with pathological compression fracture of many vertebral bodies, stationary.
      • Impression:
        • RUL cancer with slightly decrease in size of primary tumor and stationary of bony metastasis as compared with CT on 2022/07/12
    • 2022-12-05, -09-04, -08-08 CXR
      • osteolytic/blastic metastases in multiple bones of thoracic cage
      • a nodular opacity (ill-defined) over RUL, consistent a primary lung cancer, stationary
      • marginal spurs of multiple vertebral bodies due to spondylosis
      • Lt subpulmonary effusion?
    • 2022-07-13 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
      • IMPRESSION:
        • Most of above-mentioned bone lesions are old and show stationary or less evident compared with the previous study on 2022-03-09, indicating partial response to current therapy.
        • Highly suspected cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
    • 2022-07-12 MRI - brain
      • Findings: comparison 2022/03/08 MRI
        • Markedly regression of the multiple bil. cerebellar and cerebral nodules, no obvious edema was found
        • After IV contrast administration shows no obvious focal nodule.
        • Normal cisterns and sulcal systems.
        • Normal bilateral ventricular size and shapes.
        • Normal appearance of bilateral cochlear and vestibular nerves complexes.
        • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
      • Imp:
        • Markedly regression of the multiple bil. cerebellar and cerebral nodules
    • 2022-07-12 CT - chest
      • Findings: Comparison was made with previous CT dated on 20220303
        • Lungs:
          • normal appearance of RML, RLL, and left lung.
          • residual spiculated RUL tumor (26mm in longest dimension), in comparison with the previous study, the lesion is significantly dencreasing in size.
          • Mediastinum and hila: complete resolution of extensive lymphadenopathy in the visceral space and anterior prevascular space and Rtt hilum as compared with previous CT
        • Vessels:
          • Aorta: normal caliber of thoracic aorta.
          • Central pulmonary arteries: normal caliber.
          • Heart: normal in size of cardiac chambers.
        • Pleura: minimal residual bilateral effusions.
        • Visible abdominal contents:
          • Rt Lt bilateral renal cysts stone up to cm (longest axial diameter)
          • a hepatic cyst multiple hepatic cysts up to cm (longest axial diameter).
          • normal appearance of gallbladder. gall bladder stones up to cm.
          • no abnormal density and size of visible portion of the unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. bile ducts: No dilatation.
          • no enlarged lymph node.
        • Visualized bones: destructive lytic or blastic in visualized bones with pathological compression fracture of many vertebral bodies, in regression.
      • Impression:
        • RUL cancer with significant decreased size of primary tumor and resolution of mediastinal-hilar LAPs, and regression bony metastasis compared with CT on 20220303
    • 2022-07-11, -06-04, -04-07, -03-28 CXR
      • osteolytic/blastic metastases in multiple bones of thoracic cage
      • a mass opacity (ill-defined) over RUL-anterior segment along the minor fissure,consistent with a primary lung cancer,stationary
      • marginal spurs of multiple vertebral bodies due to spondylosis
      • Rt and Lt subpulmonary effusion?
    • 2022-05-04 Mammography
      • BI-RADS category 1, Negative.
    • 2022-03-30 Whole body PET scan
      • Glucose hypermetabolism in the right upper lung and right mediastinal lymph nodes, compatible with the primary lung cancer with regional lymph nodes involvement.
      • Glucose hypermetabolism in the skeleton including sternum, multiple C-, T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs, highly suspected lung cancer with multiple bone metastases.
      • Right upper lung cancer with regional lymph nodes and multiple bone metastases, cTxN2M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2022-03-09 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
      • IMPRESSION: Highly suspected cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
    • 2022-03-08 MRI - brain
      • Findings
        • Multiple bil. cerebellar and cerebral nodules, up to 14 mm in left parietal lobes.
        • After IV contrast administration shows well or heterogenous enhancement of the nodules.
        • Normal cisterns and sulcal systems.
        • Normal bilateral ventricular size and shapes.
        • Normal appearance of bilateral cochlear and vestibular nerves complexes.
        • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
      • Imp: Multiple bil. cerebellar and cerebral metastases.
    • 2022-03-04 Patho - lung transbronchial biopsy
      • Lung, RUL, CT-duide biopsy—adenocarcinoma, poorly differentiated
      • Specimen submitted in formalin consists of 3 strips of tan, irregular tissue measuring up to 0.6 x 0.1 x 0.1 cm. All for section in one cassette.
      • Sections show solid nests, acinar and cribriform glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), GATA3(-), p40(focal +), and CD56(-). The results are supportive for the diagnosis.
    • 2022-03-04 CXR
      • no pneumothorax or pleural effusion s/p transthoracic needle biopsy of RUL mass
      • osteolytic metastases in multiple bones of thoracic cage
      • bilateral pleural effusions
      • marginal spurs of multiple vertebral bodies due to spondylosis.
    • 2022-03-03 CT - chest
      • Indication: RUL mass
      • Findings
        • Chest:
          • Spiculated mass at right upper lobe up to 4.35cm in largest dimension is found. Lung cancer is considered.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Lymphadenopathy at bilateral mediastinum and bilateral axillary region.
          • Minimal atelectatic change at right middle lobe is found.
          • Bilateral pleural effusion is found.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
        • Visible brain
          • Several enhanced nodules at brain parenchyma is found. Brain meta is considered.
          • There is no evidence of destructive bone lesion.
          • No evidence of ICH, SAH or SDH.
      • Imp:
        • Right upper lobe lung cancer with mediastinal lymphadenopathy, bone meta and brain meta.
    • 2022-03-01 CXR
      • a mass opacity (ill-defined) over RUL-anterior segmnmt along the minor fissur, stationary
      • small Rt pleural effusion
      • lytic change at Rt 3rd rib, left inferior scapular body and axillary border and may be left 5th rib too due to metastases
      • old fracture of Rt 4th and Lt 4th ribs
      • hazy area of increased opacity Lt lower lung zone
      • Normal heart size
    • 2022-03-01 SONO - chest
      • Right side minimal pleural effusion; thoracocentesis was not performed due to high risk of complications.
      • Left thorax: no pleural effusion.
    • 2022-03-01 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 46) / 120 = 61.67%
        • M-mode (Teichholz) = 61
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild AR, MR
    • 2022-02-26 CXR
      • a mass opacity (ill-defined) over RUL-anterior segmnmt along the minor fissur, high possibly of a malignant lesion suggest do CT study
      • small Rt pleural effusion
      • lytic change at Rt 3rd rib, left inferior scapular body and axillary border and may be left 5th rib too due to metastases
      • old fracture of Rt 4th and Lt 4th ribs
      • hazy area of increased opacity Lt lower lung zone
      • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
      • Normal heart size
    • 2022-02-18 CXR
      • An opacity in right middle lung zone; DDx: loculated pleural effusion, mass
      • Bilateral pleural effusion
      • Normal heart size and configuration
      • Left ribs old fracture
  • chemoimmunotherapy
    • 2022-12-05 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-10-03 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-09-05 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-08-08 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-07-11 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-04-19 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-03-29 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-05-04 ~ undergoing - Giotrif (afatinib 30mg/tab) 1# QDAC

[note]

  • this patient EGFR L858R mutation detected, ROS1 (IHC 1+, FISH undetected)

  • NCCN v5.2022

    • EGFR L858R
      • Preferred
        • Osimertinib (category 1)
      • Other Recommended
        • Erlotinib (category 1)
        • or Afatinib (category 1)
        • or Gefitinib (category 1)
        • or Dacomitinib (category 1)
        • or Erlotinib + ramucirumab
        • or Erlotinib + bevacizumab,
    • ROS1
      • Preferred
        • Entrectinib
        • or Crizotinib
      • or Other Recommended
        • Ceritinib

701350013

221209

  • lab data

    • 2021-12-23 ALK IHC specimen S2021-17986
    • 2021-12-23 ALK IHC Negative
    • 2021-12-22 EGFR specimen S2021-17986
    • 2021-12-22 EGFR G719X not detected
    • 2021-12-22 EGFR Exon19 del not detected
    • 2021-12-22 EGFR S768I not detected
    • 2021-12-22 EGFR T790M not detected
    • 2021-12-22 EGFR Exon20 ins not detected
    • 2021-12-22 EGFR L858R detected
    • 2021-12-22 EGFR L861Q not detected
    • 2021-12-21 PD-L1(22C3) specimen S2021-17986
    • 2021-12-21 PD-L1(22C3) TPS < 1%
    • 2021-12-15 Anti-HCV Nonreactive
    • 2021-12-15 Anti-HCV Value 0.08 S/CO
    • 2021-12-15 HBsAg Nonreactive
    • 2021-12-15 HBsAg (Value) 0.33 S/CO
    • 2021-12-15 Anti-HBs 23.01 mIU/mL
  • exam findings

    • 2022-12-05, -11-09, -10-17, -09-21, -08-29, -08-03, -07-04,… CXR
      • an ill-defined nodular opacity with reticular opacities over Lt lower lung zone stationary
      • reticular opacities over Rt lower lung zone
      • mixed osteolytic and osteoblastic metastasis in spine
    • 2022-09-29 CT - chest
      • Indication: Left lower lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1
      • Findings
        • Chest:
          • Irregular mass like lesion attaching interlobar fissure at left lower lobe is found about 2.39cm in largest dimension. In comparison with CT dated on 2022-06-16, the lesion is stationary.
          • Calcified coronary arteries is found.
          • There is no evidence of mediastinal LAP
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • IMp: left lower lobe lung cancer with interlobar fissure attachment and bone meta. The primary tumor is stationary in size.
    • 2022-09-28 Tc-99m MDP bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone.
      • IMPRESSION: In comparison with the previous study on 2022/06/17, all of above-mentioned bone lesions are stationary, indicating multiple bone metastases in stable condition.
    • 2022-09-27 MRI - brain
      • Findings
        • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
        • The interhemispheric fissure is centered on the midline.
        • Sella and pituitary are normal. The parasellar structures are unremarkable.
        • There are no abnormalities in the cerebellopontine angle areas on both sides.
        • There are no abnormalities in the calvarium.
        • No abnormal enhancement after contrast administration.
      • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
    • 2022-06-17 Tc-99m MDP bone scan
      • In comparison with the previous study on 2022/02/11, all the previous bone lesions are less evident, suggesting multiple bone metastases with some resolution.
    • 2022-06-16 CT - chest
      • Findings
        • Chest:
          • Fibrotic mass at left lower lobe up to 2.47cm is found. In comparison with CT dated on 2022-02-10, the lesion regressed.
          • S/p port-A placement with its tip at Superior vena cava.
          • Calcified coronary arteries is found.
          • Fibrotic change at left lingula lobe, left lower lobe and right middle lobe and right lower lobe is found.
          • Calcified coronary arteries is found.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The GB is well distended without soft tissue lesion
      • IMp: Left lower lobe lung cancer with bone meta. The left lower lobe primary tumor regressed.
    • 2022-02-11 Tc-99m MDP bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone.
      • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
    • 2022-02-10 CT - chest
      • Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis
      • Findings
        • Chest:
          • Spiculated mass at left lower lobe up to 2.95cm in largest dimension is found. In comparison with previous CT performed at other hospital on 2021-11-24, the lesion regressed.
          • Minimal left pleural effusion is found.
          • Calcified coronary arteries is found.
          • Linear atelectatic change at bilateral basal lungs is found.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
        • Visible brain
          • No evidence of space occupying lesion in the brain parenchyma is found.
          • No evidence of ICH, SAH or SDH.
      • IMp:
        • left lower lobe lung cancer with primary tumor regression.
        • Bone meta. Suggest correlate with bone scan for comparison.
    • 2021-12-08 Whole body PET scan
      • Glucose hypermetablic lesion in the left lower lung, compatible with the primary lung cancer.
      • Glucose hypermetablic lesions in the left lower ribs, some T-spine, L1-3 spines with adjacent left-sided soft tissue, left S-I joint, and left iliac bone, highly suspected lung cancer with distant metastases. Please correlate with other clinical findings for further evaluation.
      • Left lower lung cancer with multiple bone metastases, cTxNxM1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2021-12-07 Patho - lung transbronchial biopsy
      • Lung, LLL, CT-guide biopsy — adenocarcinoma, poorly differentiated
      • Sections show large pleomorphic tumor cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal CK(+), TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
    • 2021-12-06 MRI - brain
      • No evidence of intracranial lesion.
  • consultation

    • 2022-06-09 Metabolism and Endocrinology
      • Q
        • This is a 52-year-old man with past history of Left lower lobe Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1, diagnosed on 2021-12; T3: LLL mass with parietal pleura invades, N0: no definite mediastinal LAPs, M1c: multiple bone metasatsis,
          • EGFR mutation: L858R (+), exon 19 (-), ALK(-), PD-L1: <1%; with chemotherapy and radiotherapy.
          • The lung cancer treatment regimen as below:
            • 1st chemotherapy with TKI Giotrif since 2021-12-29.
            • Angiogenesis inhibitor with Cyramza C1 since 2021-12-16.
            • Immunetherapy with nivo C1 on 2022-01-11 and Ipi C1 on 2022-03-28.
            • Radiotherapy 2400cGy/8 fractions to T7-8, T12-L3 and paraspinal mass, 2021-12-09 ~ 2021-12-22.
        • This time, he was admitted for TKI induced severe diarrhea, due to severe diarrhea, we hold chemotherapy and TKI with Giotrif.
        • Laboratory data showed TSH: 7.841 uIU/mL. So we sicerely need your help for evaluation. Thanks a lot!!!
      • A
        • S
          • This 52-year-old male, with past history of left lower lobe Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1, diagnosed on 2021-12, was admitted for chemotherapy and immunotherapy. We were consulted for abnormal TFT.
        • O
          • BW: 57-58 kg
          • HR: 100-114
          • Possible related medication: Nivolumab
          • AST/ALT: 19/16
          • BUN/Cr: 20/0.67
          • Na: 128, K: 2.9
          • TSH/FT4: 7.841/1.01
          • ATPO, ATG, TSH receptor Ab: unavailable
          • ACTH/Cortisol: 16.9/21.26
          • Thyroid echo: nil
        • A:
          • Suspected immunotherapy related subclinical hypothyroidism
        • Suggestions:
          • Check anti-TPO Ab, Anti-thyroglobulin Ab
          • Recheck TSH/FT4 2 weeks later
          • No need of thyroxine supplement at this moment.
          • Arrange thyroid sonography
          • Endocrine OPD F/U. Contact us if needed. I’d like to follow up this patient.
    • 2022-04-19 Dermatology
      • Q
        • This is a 52-year-old man who denied any systemic disease history. He was admitted for scheduled chemotherapy and PortA insertion for LLL cancer with spine metastasis. According to his history, he was in his usual status of health until 2021/10, when he started to note left tronchanteric area tenderness, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72 -> 56kg) in one month. Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help.
        • After spine MRI and chest CT image were obtained, he went to our OPD for help. At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis, he was admitted for CT-guided lung biopsy and further cancer staging work-up. He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted scheduled chemotherapy and port A insertion.
        • For skin rash of abdominal. We sinecrely need your professional evaluation, thank you!!
      • A
        • This patient suffered from generalized erythematous papules on whole trunk and scalp and 4 limbs for days.
        • Imp: Subacute dermatitis
        • Suggestion:
          • Zaditen (ketotifen) 1/ Bid
          • Xyzal (levocetirizine) 1 / Hs
          • Zalain Gel (sertaconazole) * 1 BT/Qd
          • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) * 6 tubes/bid
    • 2022-03-25 Radiation Oncology
      • Q
        • consult for radiotherapy
        • This is a 52-year-old man who denied any systemic disease history. He was admitted for scheduled chemotherapy for LLL cancer with spine metastasis. According to his history, he was in his usual status of health until 2021/10, when he started to note left tronchanteric area tenderness, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72->56kg) in one month. Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help. After spine MRI and chest CT image were obtained, he went to our OPD for help.
        • At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis.
        • He had started EGFR TKIs with afatinib since 2021.12.29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge, NGS liquid biopsy.
        • Bone scan reveals increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone. Some bone pain over SI and iliac joint.
        • We need your ptofessional expertise for help, thank you very much.
      • A
        • Subjective:
          • This is a 52-year-old man who denied any systemic disease history. He was in his usual status of health until 2021/10, when he started to note tenderness over left tronchanteric area, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72->56kg) in one month.
          • Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help. After spine MRI and chest CT image were obtained, he went to our OPD for help. At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis.
          • He had started EGFR TKIs with afatinib since 2021/12/29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge, NGS liquid biopsy.
          • Some bone pain over SI and iliac joint has been noted for weeks.
            • Previous RT: s/p RT to T7-8, T12, L1-3 spines, 3000cGy/10 fx, 2021/12/09-22.
            • Other disease: denied.
            • Family history: denied.
        • Objective:
          • General Condition-ECOG: 1.
          • PE, 2022/3/25: No SCF LAPs.
          • Pathology, CT-guided biopsy, 2021/12/07 10am: adenocarcinoma, poorly differentiated.
          • Images:
            • Chest CT, 2022/2/10: Spiculated mass at left lower lobe up to 2.95cm in largest dimension is found. (Se202 IM64). In comparison with previous CT performed at other hospital on 2021-11-24, the lesion regressed. Minimal left pleural effusion is found. Linear atelectatic change at bilateral basal lungs is found. Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
            • Bone scan, 2022/2/11: increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone. IMP: The scintigraphic findings suggest multiple bone metastases.
        • Diagnosis:
          • Lung cancer, LLL, PD adenocarcinoma, cT1cN0M1c, with minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord s/p RT on 2021/12/22, under EGFR TKIs with afatinib since 2021/12/29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge; ECOG: 1.
        • Suggest: Radiotherapy.
          • Goal: Palliative.
          • RT Plan:
            • Target & Volume: left S-I joint and left iliac bone.
            • Technique: IMRT by linear accelerator.
            • Dose & Fractionation: 3000cGy/10 fractions.
        • Plan:
          • RT to bone metastasis is suggested for pain control. CT simulation is arranged on March 28, 10:30am. Possible treatment toxicity (radiation dermatitis) is told. To prevent heavy weight bearing and falling accidence was told.
    • 2022-01-17 Dermatology
      • Q
        • He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted for C2 Ramu 600mg, Nivo 200mg injection treatment.
        • This time, skin rash over head and chest, we need your help, thank you a lot!
      • A
        • Skin finding: multiple erythematous papules with pustules on face, scalp and chest
        • Imp: acniform eruption due to EGFR TKI
        • Plan:
          • doxycycline 1# BID
          • clindamycin gel BID for scalp, face and chest
    • 2022-01-11 Dermatology
      • Q
        • He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted for C2 Ramu 600mg, Nivo 200mg injection treatment.
        • However, TKI related side effect was noted. paronychia and some eash over face was noted. We need your help to evalaute his problems and give further suggestion. Thanks for your kindly help.
      • A
        • Skin finding: erythematous macules and patches on T area of face
        • Imp: seborrheic dermatitis
        • Plan:
          • rinderon-V cream (betamethasone) BID topical used
    • 2021-12-10 Thoracic Medicine
      • Q
        • This is a 52-year-old male patient without underlying disease. This time he has experienced low back pain with radiation to left leg since one month ago. Cancer staging work-up revealed poorly differentiated adenocarcinoma, LLL of lung, with metastases to left lower ribs, some T-spines, L1 to L3 spines with adjacent left-sided soft tissue, left S-I joint, and left iliac bone, cT2aN0M1c, sage IVB.
        • We sincerely need your expertise for lung cancer treatment. Thank you very much!
      • A
        • Impression:
          • LLL lung cancer with lung to lung, bone metastasis, T4N0M1ic, stage IVB
        • Suggesion:
          • Check EGFR, ALK, PDL1 mutation
          • Bone radiotherapy
    • 2021-12-09 Painology
      • Q
        • This is a 52-year-old male patient without underlying disease. This time he has experienced low back pain with radiation to left leg since one month ago. Image studies were done at Cardinal Tien Hospital, and LLL lung cancer with T and L spine metastases is strongly suspected. He was admitted for cancer survey. After admission, we consulted Radiation Oncology for spine tumor radiotherapy. This time, we sincerely need your expertise for bone pain control. Thank you very much!
        • Regular medications:
          • Muaction 100 mg/SR tab (Tramadol)  1 tab     PO      TID     
          • Acetal 500 mg/tab (Acetaminophen)  1 tab     PO      TID     
          • Aelocon 50mg & 5mg/tab (Thiamine Disulfide & Riboflavin; B1 & B2)  1 tab     PO      BID     
          • Votan-SR 100mg/tab  1 TAB     PO      TID  
        • Morphine 5mg IV prnq6h use
      • A
        • S:
          • left lateral pelvis pain with radiation to inguinal area for weeks
        • O:
          • NRS (Numerical Rating Scale for pain measurement): 3-8 (after taking tramadol can remain 4-5 hours down to 3, it can be up to 8 if not well-timing; morphine IV 5mg can remain up to over night > 6 hours)
          • Touch pain, tenderness, allodynia. No rash, local heat or nodule
          • Tenderness at lateral and post waist and paraspinal area (Left L1-3 level) and left iliac
        • A:
          • Left lower lung cancer with multiple bone metastases, cTxNxM1c, stage IV
          • Susp L1-3 spine, susp left psoas or QL muscle? metastasis with intercostal nerve, ilioinguinal, genitofemoral nerve entrapement.
          • Diagnostic USG intervention: Left lumbar plexus block (T12-L1): reactive
          • US: a hypoechoic lesion over QL/Psoas muscle: soft tissue metastasis?
        • P:
          • According to latest NCCN guideline, you may shift tramadol to low dose oral morphine/oxycontin (for pain NRS > 4, low dose high potent opioids +- adjuvant medication and interventional treatment). Morphine 15mg PO Q6H-Q8H (or Oxycontin 10mg Q12H) was suggested first.
          • Due to multiple metastasis at bone/ soft tissue and his fear to intervention, I suggested that medication adjustment and RT would be better for him now.
        • Please record the pain scale and the PRN dose
    • 2021-12-06 Radiation Oncology
      • A
        • Objective:
          • General Condition-ECOG: 1. On wheel chair use due to bone pain.
          • PE, 2021/12/06: No SCF LAPs.
          • Pathology, CT-guided biopsy, 2021/12/07 10am: pending.
          • Images:
            • L spine MRI, 2021/11/23: bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord.
            • Chest CT, 2021/11/24: 23-mm tumor over LLL, small mediastinal LNs, minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord. Imp: cT1cN0M1c.
            • Brain MRI, 2021/12/06: No brain metastasis.
        • Diagnosis: Lung cancer, LLL, R/O adenocarcinoma, cT1cN0M1c, with minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord; ECOG: 1.
        • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan:
          • Target & Volume: bone metastasis over T8, T12, L1, L2.
          • Technique: IMRT by linear accelerator.
          • Dose & Fractionation: 3000cGy/10 fractions.
        • Plan:
          • RT to bone metastasis is suggested for pain control. CT simulation is arranged on Dec 07 11am. Possible treatment toxicity (radiation dermatitis and esophagitis) is told. To prevent heavy weight bearing and falling accidence was told. Diet education is given.
  • radiotherapy

  • chemoimmunotherapy

    • 2022-12-07 - Yervoy (ipilimumab) 50mg 30min
    • 2022-12-06 - Opdivo (nivolumab) 100mg 1 hr
    • 2022-12-05 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-11-12 - Yervoy (ipilimumab) 50mg 30min
    • 2022-11-11 - Opdivo (nivolumab) 100mg 1hr
    • 2022-11-10 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-10-20 - Yervoy (ipilimumab) 50mg 30min
    • 2022-10-19 - Opdivo (nivolumab) 200mg 1hr
    • 2022-10-18 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-09-23 - Yervoy (ipilimumab) 50mg 30min
    • 2022-09-22 - Opdivo (nivolumab) 100mg 1hr
    • 2022-09-21 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-09-01 - Yervoy (ipilimumab) 50mg 30min
    • 2022-08-31 - Opdivo (nivolumab) 100mg 1hr
    • 2022-08-30 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-08-05 - Yervoy (ipilimumab) 50mg 30min
    • 2022-08-05 - Opdivo (nivolumab) 200mg 1hr
    • 2022-08-04 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-07-06 - Yervoy (ipilimumab) 50mg 30min
    • 2022-07-05 - Opdivo (nivolumab) 200mg 1hr
    • 2022-07-04 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-06-13 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-05-18 - Yervoy (ipilimumab) 50mg 30min
    • 2022-05-17 - Opdivo (nivolumab) 200mg 1hr
    • 2022-05-16 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-04-20 - Yervoy (ipilimumab) 50mg 30min
    • 2022-04-19 - Opdivo (nivolumab) 200mg 1hr
    • 2022-04-18 - Cyramza (ramucirumab) 600mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-03-28 - Yervoy (ipilimumab) 50mg 30min
    • 2022-03-25 - Opdivo (nivolumab) 200mg 1hr
    • 2022-03-24 - Cyramza (ramucirumab) 600mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-03-02 - Opdivo (nivolumab) 200mg 1hr
    • 2022-03-01 - Cyramza (ramucirumab) 600mg 2hr
    • 2022-02-08 - Opdivo (nivolumab) 200mg 1hr
    • 2022-02-07 - Cyramza (ramucirumab) 600mg 2hr
    • 2022-01-11 - Opdivo (nivolumab) 200mg 1hr
    • 2022-01-10 - Cyramza (ramucirumab) 600mg 2hr
    • 2021-12-16 - Cyramza (ramucirumab) 600mg 2hr
    • 2022-08-03, 2022-08-14 ~ 2022-11-01 undergoing - Vizimpro (dacomitinib) 15mg/tab 1# QD
    • 2021-12-29 ~ 2022-07-27 - Giotrif (afatinib) 30mg/tab 1# QDAC
    • 2021-12-05, 2022-02-28, 2022-04-17, 2022-05-15 - Xgeva (denosumab) 120mg SC

==========

2022-10-19

  • The disease is characterized by L858R(+), exon19del(-), ALK(-), and PD-L1<1%. This patient has been treated with oral afatinib(2021-12 ~ 2022-07)/dacomitinib(2022-08 ~ undergoing) and IV ramu(2021-12 ~)/nivo(2022-01 ~)/ipi(2022-03 ~). It appears that the current regimen is still effective to keep the disease stable (2022-02 and 2022-06 CT: regression; 2022-09 CT: stationary).

  • The serum potassium level in 2022-10-17 was 2.9 mmol/L, and it might be beneficial to add potassium supplements.

  • The main concern for the patient and his caregiver might be pain management. For patients who require four or more doses of short-acting opioids consistently each day, addition of a long-acting opioid should be considered based on the total daily dose. A controlled-release oxycondone regimen has been prescribed to the patient since 2022-10-18.

  • In the event that the patient’s goals are not met (uncontrolled pain persists), then administer an opioid dose equivalent to 10%~20% of the total opioid taken in the previous 24 hours and reassess effectiveness and adverse effects (at 15 minutes if administered IV or at 60 minutes if administered PO).

    • pain unchanged or increased => increase dose by 50%~100%
    • pain decreased but inadequately controlled => repeat same dose
    • pain improved and adequately controlled => continue at current effective dose as needed over initial 24h

700806859

221208

{gastric cancer, T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414}

  • diagnosis - 2022-12-07 admission note
    • gastric CA. T1a pN3a (6/32) cM0,  pStage: IIB, s/p Op
    • chronic peptic ulcer, site unspecified, without hemorrhage or perforation
    • myasthenia gravis without (acute) exacerbation
  • past history - 2022-12-07 admission note
    • Myasthenia Gravis s/p thymic OP with regular using steroid control for 20 years
    • Right breast cancer s/p
    • hypothyroidism with medication control
  • current medications - 2022-12-07 admission note
    • Thyroxin 0.1mg/tab 1 TAB QW123456PO
    • Thyroxin 0.1mg/tab 2 TAB QW7
    • prednisolone 15mg QD
    • pyridostigmine 1 tab BID
  • exam findings
    • 2022-11-23 CT - abdomen
      • History: gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414
      • Findings:
        • S/P subtotal gastrectomy.
        • Moderate fatty liver, grade 4-5.
        • There is fat sparing area in S1 and S2/3.
        • S/P hysterectomy
      • Impression:
        • S/P subtotal gastrectomy.
        • There is no evidence of tumor recurrence.
    • 2022-10-03 SONO - abdomen
      • suboptimal examination of liver
      • fatty liver, severe
      • fatty infiltration of pancreas
    • 2022-09-20 CXR
      • right hemi-diaphragm elevation is noted, which may be due to eventration.
    • 2022-09-20, -06-24 KUB
      • Disc space narrowing with marginal osteophyte formation of L2-3.
      • Fecal material store in the colon.
    • 2022-04-14 Patho - stomach subtotal/total (tumor)
      • Diagnosis
        • Stomach, lesser curvature midbody, laparoscope subtotal gastrectomy with LN D2 dissection — adenocarcinoma, moderately differentiated. invading muscularis mucosa, confirmed with IHC stain of cytokeratin.
        • Lymph node, LN 1,3-9, 11p ,12a, 14v, LN D2 dissection — metastatic carcinoma
        • pT1a pN3a (if cM0); pStage: IIB, at least.
      • Gross Description:
        • Procedure: laparoscope subtotal gastrectomy with LN D2 dissection
        • Tumor Site: lesser curvature midbody
        • Tumor Size: 1.8 x 1.5 cm
        • Gross configuration: Type IIc: Flat, slightly depressed
      • Microscopic Description:
        • Histologic Type: Adenocarcinoma
          • Lauren classification of adenocarcinoma: Intestinal type
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades the muscularis mucosae
        • Margins
          • Proximal margin: uninvolved by invasive carcinoma. > 4 cm away
          • Distal margin: uninvolved by invasive carcinoma. > 4 cm away.
          • Radial margin: uninvolved by invasive carcinoma.
        • Lymphovascular Invasion: not identified.
        • Perineural Invasion: not identified.
        • Regional Lymph Nodes
          • Number of lymph nodes involved/examined: 8/32.
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIB, at least.
          • TNM Descriptors (required only if applicable): N/A.
            • Primary Tumor (pT): pT1a: Tumor invades the lamina propria or muscularis mucosa
            • Regional Lymph Nodes (pN): pN3a: Metastasis in seven to 15 regional lymph nodes
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case) (if cM0);
        • Additional Pathologic Findings- None identified
        • Ancillary Studies – IHC stains: (result of biopsy specimen S2022-06142): Her2/neu: negative (score=0)
    • 2022-04-12 Patho - stomach biopsy
      • Stomach, LC side of low body, biopsy — Adenocarcinoma.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
    • 2022-04-12 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 28) / 96 = 70.83%
        • LVEF (%) = 71
        • M-mode (Teichholz) = 71
      • Normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Normal RV systolic function.
      • Trivial MR; trivial TR; trivial PR.
    • 2022-03-29 CT - abdomen
      • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:Tx(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
      • Impression: Clinical gastric cancer, cstage T1N0M0. Suggest clinical correlation.
    • 2022-03-16 Patho - stomach biopsy
      • Stomach, low body, biopsy — Adenocarcinoma
      • Microscopically, the sections show a picture of adenocarcinoma of the gastric tissue characterized by tumor cells arranged in tubular, fused glandular or cribriform pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
      • Immunohistochemistry of CK(+) and Her2/neu (-, Dako score 1+) for tumor cells.
      • Besides, mild intestinal metaplasia and colony of Helicobacter pylori are also present.
  • consultation
    • 2022-10-19 Ophthalmology
      • Q
        • for left eye reddish & dry
        • This 55-year-old female, a pt of gastric CA. T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414 S/P C/T with FOLFOX. She was admitted for C/T.
        • She complained of left eye reddish & dry for days. We need expertise to evaluate her condition thanks!
      • A
        • Itchy and soreness ou for 3 days, redness os for days, no worsen BV
        • Gastric cancer T1a pN3a cM0, pStage: IIB, s/p op, under chemotherapy (Oxaliplatin, high-dose 5-fluorouracil)
          • HBV infection under entacavir
          • OPHx: op(-), nka
          • BCVA: OD 0.05(0.5X-2.50/-1.25X55) OS 0.05(0.5X-2.00/-1.50X95)
          • PT: 11/11mmHg
          • Pupil: 3mm, light reflex + ou, no RAPD
          • Conj: np od, temporal SCH os
          • K: clear ou
          • a/c: deep/clear ou
          • lens: co+ od, co++, psc + os
          • c/d 0.3 ou
          • fundus macula ok, retinal vessels ok ou
        • A:
          • Subconjunctival hemorrhage os
          • Cataract ou
        • P:
          • Kary 1gtt BID ou + Eyehelp 1gtt QID ou
          • oph opd f/u
    • 2022-04-15 Rheumatology
      • Q
        • This 55yo female has underlying diseases of:
          • breast cancer
          • myasthenia gravis, prednisolone 15mg QD (0413 hold) and pyridostigmine
          • hypothyroidism
        • This time, she was admitted for gastrectomy on 20220414.
        • We would like to consult your expertise for post-operative medication (IV form) adjustment due to NPO for many days.
      • A
        • History review was perdormed. Patient was admitted for gastrectomy. She has medical Hx of MG & took prednisolone 15mg QD. For post-operation NPO, I was consulted for adjusting IV form steroid dosage.
        • Suggestion:
          • Treatment as current your expert’s maangement.
          • Please add Decan 4mg IV QD for 3-7 days. Then shift to regular oral prednisolone dosage.
  • surgical operation
    • 2022-04-14 laparoscope subtotal gastrectomy with LN D2 dissection
      • subtotal gastrectomy with LN 1,3-9, 11p ,12a, 14v dissection
      • anticolic isoperistalsis B-II anastomosis
  • radiotherapy
    • 2022-05-18 ~ 2022-06-24 - 4500cGy/25 fractions (6 MV photon) to stomach and regional lymphatics
  • chemoimmunotherapy
    • 2022-12-07 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-11-04 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-19 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-09-21 - oxaliplatin 80mg/m2 135mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-25 - oxaliplatin 80mg/m2 130mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-12 - oxaliplatin 70mg/m2 118mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-07-20 - oxaliplatin 60mg/m2 100mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4790mg 46hr (adjuvant)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-06-20 - fluorouracil 225mg/m2 380mg 24hr D1-5 (adjuvant CCRT)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2022-06-13 - fluorouracil 225mg/m2 380mg 24hr D1-5 (adjuvant CCRT)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2022-06-10 - fluorouracil 225mg/m2 380mg 24hr D1 (adjuvant CCRT)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg

[assessment]

  • The serum ALT level trended upward.

    • 2022-12-07 S-GPT/ALT 61 U/L
    • 2022-11-22 S-GPT/ALT 66 U/L
    • 2022-11-14 S-GPT/ALT 66 U/L
    • 2022-10-19 S-GPT/ALT 52 U/L
    • 2022-09-20 S-GPT/ALT 58 U/L
    • 2022-08-25 S-GPT/ALT 25 U/L
    • 2022-08-16 S-GPT/ALT 36 U/L
    • 2022-08-11 S-GPT/ALT 22 U/L
    • 2022-07-26 S-GPT/ALT 14 U/L
    • 2022-07-19 S-GPT/ALT 26 U/L
    • 2022-06-20 S-GPT/ALT 14 U/L
    • 2022-06-13 S-GPT/ALT 18 U/L
    • 2022-06-10 S-GPT/ALT 26 U/L
    • 2022-06-01 S-GPT/ALT 25 U/L
  • The use of oxaliplatin has been associated with an increase in ALT levels (incidence of 36% with monotherapy)

  • There is no need to adjust the dosage of the components in the current regimen of FOLFOX.

  • The addition of pyridostigmine as a self-carried item is recommended for the patient with myasthenia gravis since this medication has no known heavy interactions with the active prescription.

700261909

221206

  • exam findings
    • 2022-12-05 CXR
      • Distention of stomach.
      • Ground glass opacity in bilateral lower lungs.
    • 2022-11-24 Patho - bone marrow biopsy
      • Bone marrow, iliac crest, biopsy — See description
      • The sections show normocellular marrow (20%). The CD71+ erythroid precursors are markedly decreased (10%). The myeloid cells show left shift in MPO stain. The CD61+ megakaryocytes are slightly increased, and few micromegakaryocytes are present. No increased CD34+ blasts. Scattered CD117+ immature cells (<3%) are present. Myelodysplastic syndrome can be considered in differential diagnosis. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2022-09-01 Patho - bone marrow biopsy
      • Bone marrow, right pelvic, biopsy — Suggested myelodysplastic syndrome
      • Sections show 10-70 % cellularity. The M/E ratio is about 4/1–5/1. Dysgranulopoiesis is seen. Anisocytosis and poikilocytosis are present. Atypical micromegakaryocytes are found about 4-7/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
      • IHC stains: CD117: 2%; CD34: <1%; CD71: 10-30%; Hemoglobin A: 10-20%; CD138: 5%. The morphology is suggesting myelodysplastic syndrome. Please correlate with the bone marrow smear, peripheral blood smear and lab data for final diagnosis.
    • 2022-08-16 Panendoscopy
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, antrum
    • 2022-07-28 SONO - abdomen
      • Liver cirrhosis with splenomegaly.
      • Left liver cyst (0.87x0.59cm).
      • S/P cholecystectomy.
    • 2022-07-12 CXR
      • Tortous aorta with calcification is noted.
      • Elevation of left hemidiaphragm is found.
    • 2022-07-06 ECG
      • Sinus rhythm with Premature atrial complexes
      • Nonspecific ST and T wave abnormality
      • Left atrial enlargement
    • 2021-03-16, 2020-09-18 SONO - nephrology
      • Parenchymal renal disease
    • 2019-11-22 CXR
      • Tortous aorta with calcification is noted.
      • Elevation of left hemidiaphragm is found.
      • Blunted left CP angle is found.
    • 2019-10-24 Flow-Volume Curve and Bronchodilator Test
      • Severe lung restriction
    • 2019-10-24, -10-22 CXR
      • Elevation of Lt hemidiaphragm may be due to LLL volume loss and fibrosis or bronchiectasis
      • bronchiectasis at Rt lung base
    • 2019-10-18 CXR
      • Elevated left hemidiaphragm.
      • Increased infiltration at RLL
  • chemoimmunotherapy
    • 2022-12-05 - Vidaza (azacitidine) 75mg/m2 100mg SC D1-D2

[assessment]

  • In the past, serum iron, total iron-binding capacity, ferritin, vitamin B12, and folate have been measured. Since the patient’s renal function appears to be in good condition, it is unlikely that the anemia is caused by low EPO levels.
  • No increase in blasts has been observed. WBC sometimes falls below normal range, RBC and HGB often fall below normal ranges. The results of the pathology indicated that MDS may be present. (with single lineage or multilineage dysplasia?) No cytogenetic del (11q, 5q, 12p, 20q,…) data available currently.
  • The patient is receiving azacitadine for the first time. Please monitor for any signs of intolerance.
  • The recommended dosing of azacitadine for patients with MDS: Initial cycle: 75 mg/m2/day for 7 days of a 28-day treatment cycle. Subsequent cycles: 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.

700307071

221206

{Left ovarian cancer (clear cell carcinoma) post Debulking surgery on 2022/06/08, pT2aN0M0, FIGO stage IIA}

  • family history
    • Father: esophageal cancer
    • Mother: lung adenocarcinoma
  • exam finding
    • 2022-11-15 CT - abdomen
      • S/P hysterectomy and oophorectomy.
      • Ground glass opacity, 0.6cm in RUL. Nature?
    • 2022-10-06 SONO - joint soft tissue
      • right shoulder supraspinatus tendinitis
      • limitation of passive movement in the glenohumeral joint, compatible with right shoulder adhesive capsulitis.
    • 2022-10-05 T-L spine AP + Lat
      • mild anterior spur formation at the middle and lower L-spine.
    • 2022-09-28 CXR
      • Atherosclerotic change of aortic arch
      • Scoliosis of the T-spine with convex to right side.
    • 2022-07-29 CXR
      • Scoliotic alignment of the thoracolumbar spine is noted.
    • 2022-06-09 Patho - ovary (tumor)
      • pathologic diagnosis
          1. Ovary, left, BSO — Mixed clear cell carcinoma and endometroid carcinoma
          1. Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/28)
          1. Soft tissue, labeled “tumor seeding on colon”, excision — Inflammation and fibrosis, no malignancy
          1. AJCC 8 th edition, Pathology stage: pT2aN0; stageIIA; FIGO stage IIA if cM0
      • macroscopic examination
          1. Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + tumor seeding on colon excision
          1. Specimen Size: 16.5 x 11.8 x 7.0 cm (Lt ovary), 2.5 x 1.0 x 0.6 cm (Rt ovary), 8.2 x 0.5 cm (Lt tube), 4.2 x 0.5 cm (Rt tube), 6.0 x 3.8 x 2.2 cm (uterus), 0.6 x 0.4 x 0.3 cm (colon tumor), 24 x 8.5 x 0.5 cm (omentum)
          1. Specimen Integrity
          • 3.1. Right ovary: Capsule intact
          • 3.2. Left ovary: Capsule ruptured
          • 3.3. Right fallopian tube: Serosa intact
          • 3.4. Left fallopian tube: Serosa intact
          1. Tumor Site: Left ovary
          1. Ovarian Surface Involvement: Present
          1. Fallopian tube Surface Involvement: Absent
          1. Tumor Size: Tri-cystic and aolid tumor, 16 x 11.8 x 7.0 cm
          1. Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
          1. Representative parts are taken for section and labeled as: F2022-00264FSA1, FSA2, FSA3= left ovary tumor, A1= left tube, A2-A10= left ovary tumor. S2022-09335 A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1= cervix, G2-G3= uterine corpus, G4= right ovary and fallopian tube, G5= left parametrium, G6= right parametrium, H= omentum, I= tumor seeding on colon.
      • microscopic examination
          1. Histologic Type: Mixed clear cell carcinoma and endometroid carcinoma
          1. Histologic grade: High grade
          1. Implants: Not identified
          1. Other Tissue/Organ Involvement: Tumor invades uterine wall
          1. Peritoneal Fluid: Not submitted
          1. Regional Lymph Nodes: All lymph nodes are negative for tumor cells (0/28)
          • number of lymph node examined: 3 (left iliac), 7 (left obturator), 4 (right iliac), 6 (right obturator), 3 (left para-aortic) and 5 (right para-aortic)
          • number with metastases >10 mm: 0
          • number with metastases 10mm or less: 0
          • number with isolated tumor cells (<=0.2mm): 0
          1. Pathologic Stage
          • 7.1. Primary Tumor: pT2a (tumor extension on the uterus)
          • 7.2. Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
          • 7.3. Distant Metastasis: Not applicable
          1. FIGO Stage: Stage IIA if cM0
          1. Lymphovascular invasion: Absent
          1. Perineural invasion: Absent
          1. Additional Pathologic Findings:
          • 11.1. Cervix: Chronic cervicitis with Nabothian cysts
          • 11.2. Endometrium: Atrophy
          • 11.3. Myometrium: Leiomyoma
          • 11.4. Ovary, right: Cortical inclusion cysts
          • 11.5. Fallopian tube, right: Para-tubal cyst
          • 11.6. Fallopian tube, left: Unremarkable
          • 11.7. Omentum: No remarkable change
          • 11.8. Specimen labeled “tumor seeding on colon”: Chronic and acute inflammatory cells infiltrate, fibrin exudate, and fibrosis
          1. IHC: Napsin A (rare + for clear cell carcinoma component), PR(+ in endometroid carcinoma), WT1(-), p53(wide type)
    • 2022-06-08 Frozen section
      • Ovary, frozen section — Malignant, favor clear cell carcinoma
    • 2022-06-08 Patho - colon biopsy
      • Colon, ileocecal valve, s/p cold snare polypectomy — Hyperplastic polyp with chronic inflammation.
    • 2022-06-06 Patho - stomach biopsy
      • Labeled as “30cm below the incisor, s/p biopsy(B)”, biopsy — benign squamous mucosa with abundant granular cytoplas, in favor of glycogenosis.
      • Stomach, LC site of antrum, s/p biopsy (A) — Chronic gastritis, H pylori NOT present
    • 2022-06-06 CT - abdomen, pelvis
      • Huge soft tissue mass at pelvis with solid and cystic component is found up to 16.5cm in largest dimension. Ovarian cancer is considered.
      • Imaging Report Form for Ovarian Carcinoma
        • Impression (Imaging stage): T:T1(T_value) N:Nx(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2022-05-30 Gynecologic ultrasonography
      • huge ovarian mass 183mm x 105mm
    • 2022-05-30 SONO - abdomen
      • suspected liver parenchymal disease, mild
      • lower abdomen tumor: cause to be determined
    • 2020-04-29 Patho - stomach biopsy
      • Stomach, low body, biopsy — fundic gland polyp. No H.pylori present
    • 2017-07-26 Mammography
      • Impression: Dense breast.
          1. Asymmetry in axillary tail region of left breast, stationary.
          1. Benign calcifications in bilateral breasts.
      • BI-RADS: Category 2: benign findings. - annual screening.
  • surgical operation
    • 2022-06-08 Debulking surgery (ATH + BSO + BPLND + paraaortic LN disection + infracolic omentectomy), Bilateral ureteral catheterization
  • chemoimmunotherapy
    • 2022-12-05 - paclitaxel 175mg/m2 260mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-11-14 - paclitaxel 175mg/m2 270mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-10-24 - paclitaxel 175mg/m2 250mg 3hr + carboplatin AUC 5 500mg 2hr (Owing to Leukopenia (ANC: 368) was noted on 20221011 and next will given Lenograstim x 3 post C/T, 2022-10-26 ~ 2022-10-28)
    • 2022-09-27 - paclitaxel 175mg/m2 250mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-09-06 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-08-15 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-07-15 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 530mg 2hr

==========

2022-09-28

  • If there is a suspicion of megaloblastic anemia (RBC 2.75 *10^6/uL, HGB 9.4 g/dL, MCV 104 fL, 2022-09-27), a vitamin B12 (cobalamin) and/or a vitamin B9 (folate) supplement might be beneficial to the patient.

701024299

221205

  • 2022-12-03 CXR

    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Bilateral pleural effusion.
  • 2022-11-21, -11-17 CXR

    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-11-18 SONO - chest

    • right side minimal amount of pleural effusion
    • left side small amount of pleural effusion, 290cc serosangious fluid was aspirated for analysis.
  • 2022-11-13 ECG

    • Sinus tachycardia
  • 2022-10-20 CT - abdomen

    • History and indication: ovary cancer with peritonal seeding right breast cancer with bone mets
    • Findings
      • Right breast cancers. Bil. pleural effusions. Enlarged LNs at left neck, mediastinum, bil. axillary regions, mesentery and retroperitoneum.
      • S/P hysterectomy. Some tumors in peritoneal cavity.
      • Tiny liver cysts. A metastases at left hepatic lobe. Progression of metastases at spleen and LUQ.
      • Swelling of right chest wall and abdominal wall.
    • IMP:
      • Right breast cancers. Bil. pleural effusions. Enlarged LNs at left neck, mediastinum, bil. axillary regions, mesentery and retroperitoneum.
      • S/P hysterectomy. Some tumors in peritoneal cavity.
      • A metastases at left hepatic lobe. Progression of metastases at spleen and LUQ.
  • 2022-10-14 CXR

    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-07-29 Whole body PET scan

    • In comparison with the previous study on 2021/12/09, the lesions in the right breast, two right supraclvicular lymph nodes, multiple right axillary lymph nodes and multiple bilateral parasternal lymph nodes are new. Primary breast malignancy with multiple lymph node metastases may show this picture. However, please correlate with the pathologic findings for further evaluation.
    • A new glucose hypermetabolic lesion in the the region about the skin of right upper back, compatible with a metastatic lesion.
    • The glucose hypermetabolic lesions in the left supraclavicular fossa, mediastinum, spleen, abdominal and pelvic cavities seem either new, more evident or larger in size, suggesting multiple metastases in progression. However, other lesions such as the lesions in the left pulmonary hilar region, pleura of right lung and left lobe of the liver are either a little less evident or disappeared.
  • 2022-07-28 CT - chest

    • History
      • 45 y/o female, a pt of ovarian CA wt peritoneal seeding, rpT3bN0 (If cM0); pStage: IIIB , FIGO stage: IIIB, s/p pre-Op NIPS wt Taxotere / Carbopaltin IV and Taxotere / Cisplatin IP Q3W x 4 finihsed in Oct 2020 s/p debulking Op on 11/30 20 by Dr Wu, s/p post-Op salvage C/T wt Taxotere/PF + IP C/T wt Taxotere / Cisplatin x 4 finished in Feb 2021 & s/p post-Op salvage Avastin 7.5mg/kg IV Q3W x 1yr since 3/9 21.
    • Findings
      • Chest:
        • Soft tissue mass/noduless at lateral breast up to 2.57cm and inner breast about 3.5cm in largest dimension. breast cancer is considered.
        • Lymphadenopathy at right axillary region, mediasitnum and paraaortic region. Lymphadenopathy from breast cancer or residual ovarian cancer is favored.
        • Very tiny nodule at right upper lobe is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Tiny low density nodules at S6 of liver about 0.34cm and 0.2cm in largest dimension. In comparison with CT dated on 2022-06-01, the lesions are stationary.
        • Low density change at splenic hilum is found. In progression.
        • The pancreas, both kidneys, adrenals are intact.
        • Suggest clinical correlation
    • Imp:
      • Right breast cancer with lymphadenopathy at right axillary, mediastinal and abdominal hepatic hilar and paraaortic region.
      • SPlenic hilar tumor, in progression.
      • Liver meta. Stable.
  • 2022-06-06 Patho - lymphnode biopsy

    • Labeled as “left supraclavicular fossa/ lymph node”, past history of ovarian and breast cancers, excision biopsy — metastatic carcinoma.
    • Section shows pieces of soft tissue with metastatic carcinoma
    • IHC stains: PAX-8 (+) and GATA-3 (-): pattern is in favor of ovarian origin rather than breast origin.
    • Residual lymph node-like tissue is present.
  • 2022-06-06 CT - abdomen

    • History and Indication:
      • 2020/08/05: Echo: susp pelvic mass with ascites.
      • OP: ATH + RSO 3 yr ago
      • 2020/08/05 CT: Cystic adenocarcinoma of ovary & carcinomatosis
      • 2020/11/30 PATHO: serous carcinoma, high grade, involved bilateral ovary, Fallopian tube and Peritoneum,rpT3bN0(If cM0); pStage:IIIB , FIGO stage: IIIB,
      • 20220309 CT: Metastases in the liver, spleen, and multiple LNs.
    • Findings:
      • S/P hysterectomy
      • Prior CT identified a metastasis 1.7 x 1.1 cm in S3 of the liver is not noted in the current CT that is c/w liver metastasis S/P C/T with complete response .
        • Prior CT identified two lobulated metastases 3 cm and 2.5 cm in between the gastrosplenic ligament, spleen, and pancreatic tail are noted again, decreasing in size to 2 cm and 1 cm that are c/w metastases S/P C/T with partial response .
        • Prior CT identiifed multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space and para-cava space are noted again, stable in size that is c/w metastatic nodes S/P C/T with stable disease .
        • Prior CT identified A enlarged node with central low density measuring 2 x 1.2 cm in left side neck is noted again, stationary.
      • Prior CT identified a cyst 4 mm in S5/8 of the liver is noted again, stationary.
      • Mild ascites in the cul-de-sac is noted.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, & both kidney.
        • There is no bowel wall thickening and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion in the omentum.
    • Impression:
      • Metastasis in the liver shows complete response.
      • Metastases in the spleen shows partial response.
      • Metastatic nodes show stable disease
  • 2022-05-31 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 18) / 62 = 70.97%
      • M-mode (Teichholz) = 71
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Trivial MR
  • 2022-05-23 Patho - lymphnode biopsy

    • Lymph node, right axillary, score biopsy — positive for invasive carcinoma
    • Microscopically, it shows presence of invasive carcinoma nestes with necrosis and stromal fibrosis in a lymphoid background.
    • IHC stain — CK(+)
  • 2022-05-23 Patho - breast biopsy (no need margin)

    • Breast, right, core biopsy — invasive carcinoma of no special type
    • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis with necrosis. The tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.
  • 2022-05-17 SONO - breast

    • Bil. fibroadenomas and cysts
    • BI-RADS: 2. benign finding
  • 2022-03-09 CT - abdomen

    • Findings:
      • S/P hysterectomy
      • There is a newly-developed poor enhancing mass 1.7 x 1.1 cm in S3 of the liver that is c/w liver metastasis.
        • There are two lobulated poor enhancing mass 3 cm and 2.5 cm in between the gastrosplenic ligament, spleen, and pancreatic tail that are c/w metastases.
        • In addition, There are newly-developed multiple enlarged nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space and para-cava space that are c/w metastatic nodes.
        • A enlarged node with central low density measuring 2 x 1.2 cm in left side neck that is c/w metastatic node.
      • Prior CT identified a cyst 4 mm in S5/8 of the liver is noted again, stationary.
    • Impression:
      • Metastases in the liver, spleen, and multiple lymph nodes.
  • 2021-12-09 Whole body PET scan

    • Multiple glucose hypermetabolic lesions in the left supracalvicular fossa, mediastinum, left pulmonary hilar region, pleura of right lung, spleen, left lobe of the liver, abdominal and pelvic cavities, compatible with multiple metastatic lesions. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the fat tissues in bilateral necks, bilateral supraclavicular fossae and bilateral paraspinal regions. Physiological FDG uptake is more likely.
  • 2021-11-26 CT - abdomen

    • Findings
      • S/P hysterectomy
      • The long segmental terminal ileum shows mild dilatation with feces-like material (Srs:302 Img:63-69) that may be partial obstruction?
        • The differential diagnosis include normal variation. please correlate with clinical condition.
        • In addition, there is a suspicious soft tissue nodule in the cul-de-sac that may be tumor seeding. The differential diagnosis include normal variation? Follow up is indicated.
      • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
    • Impression:
      • S/P hysterectomy
      • Partial obstruction of the terminal ileum and a tumor seeding in the cul-de-sac is suspected.
        • The differential diagnosis include normal variation.
        • please correlate with clinical condition.
  • 2021-11-18 SONO - abdomen

    • Hepatic lesion, right lobe, suspected cyst.
  • 2021-08-27 CT - abdomen

    • Findings
      • S/P hysterectomy -There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
    • Impression:
      • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2021-07-08 Gynecologic ultrasonography

    • ATH + BSO
    • minimal fluid
  • 2021-06-10 CT - abdomen

    • Findings
      • S/P hysterectomy. Minimal ascites in pelvic cavity.
      • Tiny liver cysts.
      • Some low attenuations in both kidneys.
    • IMP:
      • S/P hysterectomy. Minimal ascites in pelvic cavity. No evidence of tumor recurrence.
  • 2021-05-27 SONO - abdomen

    • pancreatic cystic lesion, body
  • 2021-03-10 CT - abdomen

    • Findings:
      • S/P hysterectomy
      • There is mild ascites in the pelvis.
      • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
    • Impression:
      • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2020-12-01 Patho - soft tissue tumor, extensive resection

    • PATHOLOGIC DIAGNOSIS
      • Ovary and fallopian tube? right, labeled “right pelvic peritonum”, peritonectomy — Involved by serous carcinoma
      • Round ligament of liver, peritonectomy — Involved by serous carcinoma
      • Appendix, appendectomy — Involved by serous carcinoma
      • Ovary and fallopian tube? left, labeled “left pelvic peritonum”, peritonectomy — Involved by serous carcinoma
      • Right diaphragm peritoneum, peritonectomy — Involved by serous carcinoma
      • PD tube with its tract, peritonectomy — Free of carcinoma
      • Ometum, omentectomy — Involved by serous carcinoma
      • AJCC 8 th edition, Pathology stage: ypT3bNx; stage IIIB; FIGO stage IIIB if cM0
    • MACROSCOPIC EXAMINATION
      • Procedure: Debulking surgery + peritonectomy + appendectomy
      • Specimen Size
        • Right pelvic peritonum (including right adnexa): three pieces, up to 3.2 x 2.8 x 2.5 cm
        • Round ligament of liver: 5.0 x 2.5 x 2.2 cm
        • Appendix: 4.0 x 1.0 x 1.0 cm
        • Left pelvic peritoneum (including left adnexa): three pieces, up to 3.4 x 2.9 x 2.8 cm
        • Right diaphragm peritoneum: multiple pieces up to 12.5 x 8.0 x 4.5 cm
        • PD tube with its tract: 8.0 x 0.9 cm with tract 5.0 x 1.2 cm
        • Omenum: 22.0 x 11.0 x 1.5 cm
      • Specimen Integrity: Fragmented
      • Tumor Site: Both adnexa
      • Ovarian Surface Involvement: Present
      • Fallopian tube Surface Involvement: Present
      • Representative parts are taken for section and labeled as: A1-A3= right pelvic peritonum (including right ovary and fallopian tube), B1-B3= round ligament of liver, C1-C2= appendix, D1-D3= left pelvic peritoneum (including left ovary and fallopian tube), E1-E3= right diaphragm peritoneum, F= PD tube with its tract, G1-G3= omentum
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Serous carcinoma
      • Histologic grade: High grade
      • Ovary and fallopian tube? right, labeled “right pelvic peritonum”: Involved by serous carcinoma
      • Round ligament of liver: Involved by serous carcinoma
      • Appendix: Involved by serous carcinoma
      • Ovary and fallopian tube?left, labeled “left pelvic peritonum”: Involved by serous carcinoma
      • Right diaphragm peritoneum: Involved by serous carcinoma
      • PD tube with its tract: Chronic inflammation, fibrosis and free of carcinoma
      • Ometum: Involved by serous carcinoma
      • Pathologic Stage
        • Primary Tumor: ypT3b (macroscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimension)
        • Regional Lymph Nodes: Not submitted
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIB if CM0
      • Additional Pathologic Findings: Psammoma bodies
  • 2020-11-30 Patho - ovary (tumor)

    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, debulking surgery (s/p neoadjuvant treatment) — serous carcinoma, high-grade
      • Ovary, left, debulking operation — serous carcinoma, high-grade
      • Fallopian tube, right, debulking operation — involved by serous carcinoma
      • Fallopian tube, left, debulking operation — involved by serous carcinoma
      • Lymph node, right iliac, dissection — negative for malignancy ( 0 / 3 )
      • Lymph node right obturator, dissection — negative for malignancy ( 0 / 1 )
      • Lymph node, left iliac, dissection — negative for malignancy ( 0 / 4 )
      • Lymph node, left obturator, dissection — negative for malignancy ( 0 / 1 )
      • Pelvic mass, debulking surgery — involved by serous carcinoma
      • Omentum, debulking surgery — involved by serous carcinoma
      • pTNM: rpT3bN0 (If cM0); FIGO stage: IIIB; pStage:IIIB
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: debulking surgery
      • Specimen type: bilateral ovaries, fallopian tubes, regional LNs, omentum
      • Specimen size:
        • right ovary: 4.2x 3.5x 2.2 cm;
        • left ovary: 5x 4x 2.5 cm;
        • right tube: 4.5 cm in length;
        • left tube: 4.5 cm in length;
        • uterus: not received
      • Tumor site: right and left ovaries
      • Tumor size: up to 1.3 cm in size
      • Tumor appearance: solid and papillary
      • Specimen integrity: Ovarian capsule ruptured (right)
      • Lymph node: (tissue size) up to 1 cm
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: present
      • Right tube involvement: present
      • Left tube involvement: present
      • In situ adenocarcinoma in right and/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: present (labeled pelvic mass)
      • Uterine serosa involvement: non-applicable
      • Omentum involvement: present
      • Uterine Cervix involvement: N/A
      • Endometrium involvement: N/A
      • Myometrium involvement: N/A
      • Appendix involvement: N/A
      • Lymph nodes metastasis:
        • Group as specified No. Positive / No. Total
        • Right iliac ( 0 / 3)
        • Right obturator ( 0 / 1 )
        • Left iliac ( 0 / 4 )
        • Left obturator ( 0 / 1 )
      • Other organs or specimens involvement: none
      • Immunohistochemical stain shows WT-1(+), CK7(+), CK20(-)
  • 2020-11-18 Whole body PET scan

    • Glucose hypermetabolism in the left pelvis, compatible with the CT findings of much regression of ovary cancer and peritoneal carcinomatosis with residual tumor at the left ovary.
    • Glucose hypermetabolism in bilateral palatine tonsils, probably chronic inflammation/infection process.
    • Glucose hypermetabolism in bilateral pulmonary hilar regions, probably physiological uptake of FDG or reactive nodes.
    • Increased FDG accumulation in the colon and urinary bladder, physiological FDG accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2020-11-18 Gynecologic ultrasonography

    • ATH
    • Suspected Lt ovarian mass: 48x42mm
  • 2020-11-16 CT - abdomen

    • History and indication: ovary cancer with peritonal seeding
    • Findings
      • Much regression of ovary cancer and peritoneal carcinomatosis (residual tumor at left ovary).
      • Thyroid nodules (3-5mm).
      • Tiny liver cysts.
      • Some low attenuations in both kidneys.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Much regression of ovary cancer and peritoneal carcinomatosis (residual tumor at left ovary).
  • 2020-10-28, -09-16, -09-15, -08-26, -08-25, -08-13 Body fluid cytology - ascites

    • Malignancy
  • 2020-08-13 Patho - peritoneum biopsy

    • Labeled as “ovary cancer with diffuse peritoneal seeding”, biopsy — adenocarcinoma
    • Section shows adenocarcinoma.
  • 2020-08-07 Patho - ovary biopsy/wedge resection

    • Labeled as “s/p 3 yr rt partial ovrain tumor excision, intraabd peritoenal tumor with ascite”, biopsy — adenocarcinoma, serous type, high grade.
    • Section shows piece of tissue with short papillae of neoplastic cells containing hyperchromatic nuclei and abundant eosinophilic cytoplasm.
    • IHC stains: PAX-8 (+), WT-1 (+), CK20 (-), a pattern of ovarian origin.
    • IHC stains: ER (+, 1-5%, moderate intensity); PR (+, 1-5%, moderate intensity).
  • 2020-08-06 Gynecologic ultrasonography

    • ATH + RSO
    • Imp:
      • Ascites
      • Suspected Lt ovarian mass (RI: 0.13) 144x106mm, malignancy cannot be ruled out.
  • 2020-08-05 CT - abdomen

    • Findings:
      • There is a large multilocular mixed cystic and solid masses in the pelvis that may be cystic adenocarcinoma of the ovary. please correlate with clinical history.
      • There is massive ascites and soft tissue nodules in the omentum and right perihepatic space (Srs:3, Img:25) that is compatible with carcinomatoais.
      • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst. The differential diagnosis include metastasis. Please correlate with sonography.
    • Impression:
      • Cystic adenocarcinoma of the ovary with carcinomatosis is highly suspected. please correlate with clinical condition.
      • A hepatic cyst 4 mm in S5/8 is suspected. The differential diagnosis include metastasis. Please correlate with sonography.
  • 2020-08-05 SONO - abdomen

    • Diagnosis
      • Suspected pelvic mass lesion
      • Ascites with peritoneal nodule; D/D: peritonitis, carcinomatosis
    • Suggestion
      • CT scan
      • GYN survey
  • 2020-05-16 Mammography

    • Impression: Dense breast. Probably benign calcifications in bilateral breasts.
    • BI-RADS: Category 2: benign findings.-annual screening.
  • consultation

  • chemoimmunotherapy

    • 2022-06-07 doxorubicin 50mg/m2 70mg 10min + cyclophosmamide 500mg/m2 700mg 1hr
    • 2021-11-16 bevacizumab 17.5mg/kg 375mg 1.5hr
    • 2021-10-26

700356362

221202

{Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1}

  • diagnosis
    • malignant neoplasm of appendix
    • secondary malignant neoplasm of retroperitoneum and peritoneum
    • hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
    • anemia, unspecified
  • exam finding
    • 2022-11-17, -09-29 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Nodular and linear opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
    • 2022-09-09 ECG
      • Sinus bradycardia with Premature atrial complexes
    • 2022-09-08 24hr portable ECG
      • Sinus rhythm
      • Occasional isolated apcs
      • Rare apc couplets
      • Rare episodes short run atrial tachycardia (longest: 11 beats)
      • Rare isolated vpcs
      • No long pause
      • No significant tachyarrhythmia
      • Frequent sinus bradycardia even at day-time, please correlate with clinical and drug history to r/o chronotropic incompetence
    • 2022-09-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 31) / 146 = 78.77%
        • M-mode (Teichholz) = 78
      • Mild septal hypertrophy with indeterminated LV filling pressure; moderately dilated LA.
      • Dilated LV with normal LV and RV systolic function.
      • Prominent aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
      • Dilated aortic root with mild calcification.
      • Sinus bradycardia.
    • 2022-09-06 ECG
      • atrial fibrillation with slow ventricular response
    • 2022-07-08 Flow volume loop and volume time curve
      • mild restrictive ventilatory impairment
    • 2022-07-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (147 - 56) / 147 = 61.90%
      • Dilated LA, LV, Ao
      • Adequate LV, RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild MR,TR,AR
    • 2022-06-30 Electroencephalogram, EEG
      • normal awake EEG with alpha rhythm 9-10Hz.
    • 2022-06-07 CT - chest
      • Findings
        • Lungs:
          • lobular areas of consolidation and centrilobular nodular and branching opacities as well as septal thickening at LLL, RML and RLL, in progression.
          • centrilobular nodular and branching opacities at posterior RUL.
          • subsegmental consolidation with centrilobular nodular and branching opacities at LLL.
        • Mediastinum and hila: a 5 mm nodule in thymic bed.
        • Several mildly enlarged LNs in visceral space.
        • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
        • pulmonary arteries: normal caliber and well opacification.
        • Heart: normal in size of cardiac chambers.
        • Pleura: small bilateral effusions.
        • Visible abdominal-pelvic contents: s/p peritoneal drains in place.
          • extensive and large soft-tissue mass at anterior peritoneal cavity, displacing and compressing liver surface, with Rt perihepatic loculated ascites, and moderate free ascites.
          • several small Rt renal cysts.
          • unremarkable of the spleen, adrenal glands, the pancreas.
      • Impression:
        • lung infection in progression. hyperplastic reactive mediastinal LNs.
        • peritoneal carcinomatosis.
    • 2022-06-06 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Nodular and linear opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
    • 2022-05-09 Chest XR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Nodular opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
    • 2022-04-12 CT - CTA, chest
      • Findings
        • Lungs:
          • lobular areas of consolidation and centrilobular nodular and branching opacities at RML and RLL. centrilobular nodular and branching opacities at posterior RUL.
          • subsegmental consolidation with centrilobular nodular and branching opacities at LLL.
          • ground glass nodule solid nodule at RUL RML RLL LUL LLL (up to 2. Mediastinum and hila: a 5 mm nodule in thymic bed.
        • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
        • pulmonary arteries: normal caliber and well opacification.
        • Heart: normal in size of cardiac chambers.
        • Pleura: small Lt-sided effusion.
        • Visible abdominal-pelvic contents:
          • extensive and large soft-tissue mass at anterior peritoneal cavity, displacing and compressing liver surface, with Rt perihepatic loculated ascites.
          • several small Rt renal cysts.
          • unremarkable of the spleen, adrenal glands, the pancreas.
      • Impression:
        • no pulmonary embolism.
        • lung infection or aspiration pneumonia.
        • peritoneal carcinomatosis.
    • 2022-04-02 Chest PA/AP view
      • Supine chest image shows:
        • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
        • reticular opacities over Lt lower lung zone
        • marginal spurs of multiple vertebral bodies
    • 2022-03-28 Body fluid cytology - ascites
      • Atypia
      • Smears show mucinous material, neutrophils and reactive mesothelial cells.
    • 2022-01-17 Tc-99m MDP whole body bone scan
      • Faint hot spots in the left 11th costovertebral junction and both rib cages, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for further evaluation.
      • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, hips, and ankles.
    • 2022-01-17 MRA - brain
      • Mild general brain atrophy. Left mastoiditis. Bilateral chronic paranasal sinusitis.
    • 2022-01-13 CT - CTA, chest
      • Post op. change of the abodominal cavity.
      • Locualted effusion at RLQ of the abdomen. Nature?
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Some small patches at both lungs. suspected infection.
    • 2022-01-13 CT - brain
      • Mild ventriculomegaly. Intracraniaal artherosclerosis.
    • 2022-01-13 KUB
      • The psoas shadow is clear.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • Increased intestinal gas is found.
      • Osteopenia of the bony structure is noted.
    • 2021-12-31 Patho - soft tissue tumor, extensive resection
      • pathologic diagnosis
        • Peritoneum, RUQ and right flank, peritonectomy - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
        • Round ligament of liver, excision - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
        • Greater omentum, omentectomy - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
      • microscopic examination
        • The sections show a picture of pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1, composed of abundant mucin with scant cohesive strips of low-grade mucinous epithelium.
    • 2021-12-27 Patho - pleural/pericardial biopsy
      • Lung, left, CT-guide biopsy - interstitial fibrosis and chronic inflammation - atypical pneumocyte present
      • Sections show alveolar lung tissue with interstitial fibrosis, chronic inflammatory cell infiltration and atypical pneumocyte proliferating along the alveolar wall.
      • No granuloma or malignancy is found.
      • IHC: CK7(+), CK20(-), TTF-1(+), Napsin A(+), and CDX2(-).
    • 2021-12-14 CT - lung/mediastinum/pleura
      • lung infection or aspiration pneumonia.
      • peritoneal carcinomatosis. RUQ free air due to infection or prior abdominal intervention.
    • 2021-12-06 Patho - peritoneum biopsy
      • diagnosis
        • Omentum, biopsy - metastatic mucinous adenocarcinoma, origin?
        • Peritoneum, biopsy - metastatic mucinous adenocarcinoma, origin?
      • IHC: CK7(-), CK20(+), CDX2(+), and PAX8(-). The results are in favor of GI tract (including appendix) tumor.
    • 2021-12-03 Colonoscopy
      • mixed hemorrhoid
      • no tumor was found in colonic lumen
  • consultation
    • 2022-09-08 Cardiology
      • Q
        • For bradycardia was noted last night, associated symptoms with syncope, chest tightness, we need your further evaluation and management.
        • The patient is an 72-year-old man with a history of Benign prostatic hyperplasia with Hamalidge OCAS control, Appendix cancer with peritoneal metastatic mucinous adenocarcinoma, cT4aN1aM1, stage IVA status post laparoscopic examination and biopsy on 2021/12/06, immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), with IP chemotherapy (Docetaxel + cisplatin 60ml each with N/S 500ml and Gentamycin + Jusomin equally split to port-a at abdomen and oral chemotherapy with TS1 25mg/cap 3cap QD for one weeks and add IV chemotherapy.
      • A
        • S
          • This is a 72 years old man who was admitted for chemotherapy for appendiceal cancer.
          • We were consulted for near syncope survey. She is currently in abdominal pain for intraperitoneal assess route catheter infection.
        • O
          • Vital sign : stable
          • 2022/07/08 echography showing
            • EF: 66%
            • Dilated LA, LV, Ao
            • Adequate LV, RV systolic function with normal wall motion
            • Thick IVS, Impaired LV relaxation
            • Mild MR, TR, AR
          • EKG: sinus bradycardia with poor isoelectric line.
        • Impression
          • Near syncope rule out vaso-vagal. syncope or sick sinus syndrome
          • PD assess site infection under tapimycin
          • Sinus bradycardia.
        • Suggestion
          • Adequate pain control and fluid support
          • to check BP and HR at supine, sitting and standing position with 5 mins of interval to exclude postural hypotension
          • to check thyroid function and to arrange 24 H holter monitor due to marked sinus bradycardia episode.
          • Consider to consult neurology for neurogenic cause.
    • 2022-01-14 Neurology
      • Q
        • For seizure evaluation
        • This 72 y/o male has history of BPH. He just discharge on 20220108 due to mucinous adenocarcinoma of appendix with peritoneal metastatic, cT4aN1aM1, stage IVA, status post omentectomy and peritonectomy and PD tube inserted and intraperitoneal port implantation + HIPEC on 20211230.
        • According to his statement, he suffered from chest tightness, dyspnea since yesterday. He went to our ER for help on 20220113. His EKG data showed NSR, cardiac enzyme within normal range, D-dimer: 3730ng/ml. Unfortunately, he had seizure(hanging eyes) for 5 seconds at ER, Ativan and Keppra stat were given. Brain CT without constrast was done and showed mild ventriculomegaly, intracranial atherosclerosis. Chest CTA was done it revealed (1) no evidence of pulmonary embolism nor aortic dissection, (2) left pleural effusion and minimal right pleural effusion, (3) locualted effusion at RLQ of the abdomen. Nature?, (4) Some small patches at both lungs. suspected infection. Now, his con’s clear, stable of vital sign, pupil size 3.0 (OU) light reflux, four limbs muscle power 5point. We need your expertise for seizure evaluation and management. Thanks for your times.
      • A
        • Due to seizure at ER, we are consulted. Patient told he had no history of seizure and he didn’t remember during seizure attack. He also denied tongue biting, urinary/bowel incontinence, todd’s paralysis, diplopia, swallowing problem, slurred speech, limbs numbness or limbs weakness.
        • NE
          • Consciouness: E4V5M6
          • Visual field: no hemianopia
          • EOM: free
          • Pupil: 3.0/3.0 mm, Light reflex: +/+
          • Face: no central facial palsy
          • No dysarthria
          • no tongue deviation
          • Muscle power: 5/5
          • Babinski: down/down
          • Sensory: no hypoesthesia
          • FNF & HKS: no dysmetria
          • D dimer : 3700, Na 124, CRP 4.9
        • Assessment
          • Generalized tonic clonic seizure, 1st episode, suspected metastasis related or electrolyte imbalance
          • mucinous adenocarcinoma of appendix, stage IV A
        • Suggestion
          • Arrange EEG and MRA brain with/without contrast to r/o metastasis
          • Vit B6 1# bid po and Keppra 500mg bid po for seizure
          • We have given seizure educations to caution on driving scooter/car
    • 2022-01-06 Hemato-Oncology
      • Q
        • For further bidirectional chemotherapy evaluation
        • This 71 years old male has history of benign prostatic hyperplasia under medication treatment. According to his statement, he suffered from abdomen fullness for half year and body weight loss 4 kgs within 6 months, ever has tarry stool at 3 months ago. Then the symptom of RLQ pain worse since 2021-09, so he went to the Shin Kong Hospital for help.
        • On 2021-11-25 abdomen CT showed (1) Ruptured appendix mucinous cancer with peritoneal carcinomatosis, omental caking and hepatic surface implantation, (2) Focal peribronchial inflammation. And he was admitted to our Oncology ward for survey on 2021-11-29. During last admitted, he underwent laparoscopic examination with peritoneal tumor biopsy was done on 2021-12-06.
        • The pathology revealed metastatic mucinous adenocarcinoma. On 2021-12-14 following chest and abdomen CT was performed which showed (1) lung infection or aspiration pneumonia, (2) peritoneal carcinomatosis. Abdomen echo was done and showed no GB stone. Heart echo revealed LVEF: 80%, aortic valve sclerosis with mild AR; mild to moderate MR; mild TR; moderate PR. We check tumor marker showed CEA: 10.93ng/ml, CA-199: 283.12U/ml.
        • Under stable condition condition and fair oral intake, he was discharge on 20211215. After discharge, he was followed at GS OPD. He denied of poor appetite, no nausea or vomit, no tarry stool, no bloody stool, no abdomen fullness, no abdomen pain. Physical examination showed andomen ovoid and soft, no tenderness, no palpable mass. After fully explain, right hemicolectomy and cytoreductive surgery and HIPEC was suggested. This time, he was admitted to our ward for lung lesion biopsy and surgical intervention. However, during operation his PCI: 29/39 was noted, thus underwent omentectomy, peritonectomy, CAPD and IP port implantation and HIPEC with oxaliplatin 300mg/m2 was done on 20211230. Now, he try to semi-liquid diet was smoothly, normal bowel function and stable condtion. We need your expertise for further bidirectional chemotherapy evaluation. Thanks for your times.
      • A
        • This 71 years old man is a case of Appendix cancer with peritoneal metastatic mucinous adenocarcinoma, cT4aN1aM1, stage IVA status post laparoscopic examination and biopsy on 2021/12/06, immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and PAX8(-), ECOG:0 s/p omentectomy, peritonectomy, CAPD and IP port implantation and HIPEC with oxaliplatin 300mg/m2 was done on 20211230. For bidirectional chemotherapy, we are consulted.
        • The impact of adjuvant chemotherapy following CRS/HIPEC in appendiceal mucinous neoplasms has not been well established due to rareness of this disease and lack of randomized trials. In the advanced-disease setting, available retrospective data suggest beneficial effect from systemic chemotherapy in moderate- to high‐grade appendiceal mucinous tumors.
        • Systemic therapy with FOLFOX/bevacizumab +/- IP chemotherpay as ajuvant chemotherapy may consider in this case
        • We will disucss with patient, thanks for your consultation
    • 2021-12-09 General and Gastroenterological Surgery
      • Q
        • for metastatic mucinous adenocarcinoma surgery, prepare the IP chemotherapy and on port-a evaluation
        • This time, he is admitted for colonfibroscopy examination and biopsy and staging, follow-up colonoscopy: no tumor was found in colonic lumen on 20211203, and he received the laparoscopy for tumor biopsy showed metastatic mucinous adenocarcinoma, origin? The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and PAX8(-). The results are in favor of GI tract (including appendix) tumor. So we need your help for metastatic mucinous adenocarcinoma (for peritoneum biopsy) surgery, prepare the IP chemotherapy and on port-a evaluation, thanks a lot!!
      • A
        • impression
          • psudomyxoma with peritoni, favor appendical mucinous adenocarcinoma related
        • suggest
          • radical right hemicolectomy with cytoreductive surgery and HIPEC is indicated
          • please arrange 2D echo and PFT first
          • please transfer to our survice next Monday
          • PPN support
  • surgical operation
    • 2021-12-30
      • omentectomy
      • RUQ and right flank peritonectomy
      • CAPD (continuous ambulatory peritoneal dialysis)
      • IP port implantation
    • 2021-12-06 Laparoscopic exploration and biopsy
      • Post-Op Dx: suspect pseudomyxoma peritoni        
      • Finding
        • Multiple white nodular lesions within omentum and peritoneal surface were noted. pieces were excised of them for biopsy.
        • Gelly like ascites about 100 ml and ascites cytology was done.
  • chemotherapy
    • 2022-12-01 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-11-18 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-11-04 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-10-17 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-09-30 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-08-15 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr (The patient complaints poor intake due to the oral chemotherapy, so shift to TS1 25mg/cap 3cap QD for one week)
    • 2022-06-06 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-05-10 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-04-15 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-03-25 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
    • 2022-03-04 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
    • 2022-02-09 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?

==========

2022-12-02

  • The vital signs are stable, and laboratory results indicate a grossly normal condition, except for hypomagnesemia (2022-12-01 1.6 mg/dL) which is being treated with magnesium sulfate injection.

2022-09-06

  • If neoadjuvant or adjuvant systemic chemotherapy is needed, a combination of fluoropyrimidine and an alkylating agent is recommended. 5-FU (TS-1) and oxaliplatin were included in the regimen used in the last hospitalization (2022-08-15). (ref: Lin, YL. et al. Consensuses and controversies on pseudomyxoma peritonei: a review of the published consensus statements and guidelines. Orphanet J Rare Dis 16, 85 (2021). https://doi.org/10.1186/s13023-021-01723-6 ).
  • Due to the patient’s poor intake caused by TS-1, the regimen has been changed to 7 consecutive days of administration. If this is also followed by a week of rest, thereby making the cycle 14 days, then the dose of oxaliplatin might need to be adjusted to accommodate this modification in cycle length.

2022-06-07

  • This case represents a patient with pseudomyxoma peritonei (PMP), who underwent omentectomy, RUQ, and right flank peritonectomy in 2021-12-30 along with hyperthermic intraperitoneal chemotherapy (HIPEC).
  • The patient has been receiving intraperitoneal treatment with [docetaxel + cisplatin + gentamicin] since 2022-02-09 in conjunction with oral TS-1, a regimen that has been outlined at doi:10.3390/cancers12082212.
  • Since records began in Nov 2021, certain items of lab results have been consistently outside normal ranges. These include low HGB (2022-06-07 8.7g/dL), low RBC (2022-06-07 2.61 106/uL), and high D-dimer (2022-06-06 6969.93 ng/mL FEU).
  • Anemia is rarely mentioned in PMP case reports, so it is possible that anemia could be caused by another condition which might be worth further investigation.
  • TPR and BP are generally normal and stable since this hospital stay from 2022-06-06.

2022-06-06

[drug identification]

Total 1 drug for identification.

The identified item is Vemlidy film-coated tablet containing tenofovir alafenamide 25mg which is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease.

The drug will be sent back to ward by the in-hospital porter.

2022-04-06

  • This is a patient with pseudomyxoma peritonei (PMP), s/p omentectomy, RUQ and right flank peritonectomy (2021-12-30) and hyperthermic intraperitoneal chemotherapy (HIPEC).
  • From 2022-02-09, he has been receiving intraperitoneal [docetaxel plus cisplatin + gentamicin] in combination with oral TS-1, a regimen which was published at doi:10.3390/cancers12082212.
  • Hypoosmolarity and hypoelectrolytemia are treated with appropriate electrolyte solutions.
  • A low WBC reading of 910/uL was recorded on 2022-04-05. G-CSF might be an option.

700561561

221202

{pancreatic cancer, endometrial cancer}

  • diagnosis
    • Pancreatic cancer with peritoneum metastasis s/p Laparoscopic exploration on 2022/02/25
    • Endometrial cancer, pT1bN0M0, Stage IB status post laparoscopic vaginal total hysterectomy on 2018/04/17
  • lab data
    • CEA
      • 2022-07-26 CEA 5.21 ng/mL
      • 2022-05-02 CEA 3.10 ng/mL
      • 2022-01-24 CEA 1.96 ng/mL
      • 2021-10-25 CEA 1.84 ng/mL
    • CA125
      • 2022-07-26 CA125 788.2 U/mL
      • 2022-05-02 CA125 460.8 U/mL
      • 2022-01-24 CA125 15.1 U/mL
      • 2021-10-25 CA125 5.8 U/mL
      • 2021-07-26 CA125 5.5 U/mL
      • 2021-04-26 CA125 3.5 U/mL
    • CA199
      • 2022-07-26 CA199 12024.11 U/mL
      • 2022-05-23 CA199 >19680.00 U/mL
      • 2020-04-13 CA199 23.72 U/mL
  • exam finding
    • 2022-11-28 CT - abdomen
      • Indication: Pancreatic cancer with peritoneal carcinomatosis
      • Findings
        • Abdomen and pelvis
          • Low density change at pancreatic tail about 4.74cm in largest dimension is found. pancreatic cancer is considered. In comparison with CT dated on 2022-09-05, the lesion is stationary.
          • Massive ascites is found. Cancerous peritontitis is considered first
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Low density lesion at S4 of liver about 2.5cm in largest dimension is found. Liver meta is considered. In progression.
          • No evidence of abnormal soft tissue mass at pelvic cavity.
          • The spleen, pancreas, both kidneys and adrenals are intact.
        • Visible chest
          • Cardiomegaly is noted.
          • No pleural effusion is found.
          • Clear bilateral basal lungs.
        • Suggest clinical correlation
      • Imp:
        • Pancreatic tail cancer with cancerous peritonitis and massive ascites. Stable.
        • Liver meta. In progression.
        • Bone meta. Please correlate with bone scan study.
    • 2022-11-16 CXR
      • Fracture of left clavicle, M/3.
      • Pleura effusion of right and left costal-phrenic angle
      • Atherosclerotic change of aortic arch
    • 2022-09-05 CT - abdomen
      • Indication: Pancreatic cancer with peritoneal seedings
      • Findings
        • Abdomen and pelvis
          • s/p ATH and BSO.
          • Low density lesion at pancreatic tail about 4.6cm is found. In comparison with CT dated on 2022-05-09, the lesion is stationary.
          • Massive ascites is found. Cancerous peritonitis is considered.
          • The GB is well distended without soft tissue lesion
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Low density lesion at S4 of liver about 0.7cm in largest dimension is found. suspected liver meta or others. Stationary.
          • There is no evidence of paraarotic LAPs.
        • Visible chest
          • Normal heart size.
          • The lung fields are clear.
          • No pleural effusion is found.
        • Suggest clinical correlation
      • Imp:
        • Massive ascites, suspected cancerous peritonitis
        • Pancreatic tail tumor, 4.6cm, stable. Pancreatic cancer is favored.
        • Bone meta. New.
        • Liver low density lesion. S4, meta?
    • 2022-06-14 SONO - abdomen
      • Gallbladder sludge
      • Asictes
    • 2022-06-10 CXR
      • S/P port-A implantation.
      • Fracture of left clavicle, M/3.
      • Pleura effusion of right and left costal-phrenic angle
      • Atherosclerotic change of aortic arch
    • 2022-06-09 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 18 dB HL; LE 24 dB HL
      • bil normal to moderate SNHL (sensorineural hearing loss)
    • 2022-05-25 Patho - peritoneum biopsy
      • Peritoneum, biopsy — Metastatic adenocarcinoma, origin? (please see microdescription)
      • Section shows fibroadipose tissue with metastatic adenocarcinoma.
      • The immunohistochemical stians reveal CK7(+), CD20(-), CDX2(focal weak +), GATA3(+), PAX8(-), and Calretinin(-).
      • The results are more favor pancreatic tumor than endometrial tumor.
    • 2022-05-25 Patho - omentum biopsy
      • Greater omentum, biopsy — Negative for malignancy
    • 2022-05-24 ECG
      • Sinus tachycardia
      • Low voltage QRS
    • 2022-05-24 SONO - abdomen
      • massive ascites
      • diffuse wall-thickening of small bowel, suspected carcinomatosis
    • 2022-05-13 Clavicle LT
      • Left M/3 clavicle fracture
    • 2022-05-09 CT - abdomen, pelvis
      • s/p ATH and BSO.
      • Massive ascites and bilateral pleural effusion is found.
      • Pancreatic body lesion about 5.53cm in largest dimension is found. Either meta or primary tumor should be D.D.
    • 2022-05-09 Gynecologic ultrasonography
      • p/s ATH + BSO
      • Ascites (+)
    • 2022-05-04 Gynecologic ultrasonography
      • Bil adnexa: s/p BSO
      • EM cancer post staging, ascites (+)
      • suspected tumor recurrence
    • 2022-05-04 KUB
      • Presence of ileus.
    • 2022-05-04 CXR
      • Fracture of left clavicle.
      • Left pleural effusion.
      • Presence of ileus.
    • 2022-04-01 Clavicle LT
      • Left M/3 clavicle fracture with displacement
    • 2022-01-26 CT - abdomen, pelvis
      • S/P hysterectomy. There is no evidence of tumor recurrence.
      • A lesion in S4 liver shows stationary.
      • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
    • 2021-11-01 Gynecologic ultrasonography
      • p/s ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2021-07-26 CT - abdomen, pelvis
      • S/P hysterectomy.
      • No evidence of tumor recurrence.
    • 2021-05-03 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Hepatic high echoic lesions, nature? fibrosis lesions?
        • GB stones
        • Fatty pancreas
      • Suggestion
        • Please correlate with clinical information and other image studies, and follow sonography in 3-6 mon.
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2021-05-03 Gynecologic ultrasonography
      • p/s ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2020-10-07 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Hepatic low echoic lesions, nature?
        • GB stones
        • Fatty pancreas
      • Suggestion
        • Please correlate with clinical information and other image studies, and follow sonography in 3-6 mon.
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2020-07-27 CT - abdomen, pelvis
      • S/P hysterectomy.
      • No evidence of tumor recurrence.
    • 2020-04-13 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • GB stones?
      • Suggestion
        • Please follow sonography in 3-6 mon.
    • 2020-04-13 Gynecologic ultrasonography
      • p/s ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2020-01-03 CT - abdomen
      • S/P hysterectomy. There is no evidence of tumor recurrence.
      • A lesion in S4 liver is suspected. Follow up MRI 3 months later may be indicated.
      • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
    • 2019-09-26 Transvaginal Ultrasonography
      • No obvious uterine or ovarian lesion
    • 2019-06-03 CT - abdomen
      • S/P hysterectomy. There is no evidence of tumor recurrence.
      • A lesion in S4 liver is suspected.
      • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
    • 2019-02-25 Transvaginal Ultrasonography
      • No obvious uterine or ovarian lesion
    • 2018-11-27 CT - abdomen
      • s/p ATH and BSO.
      • No focal lesion in the pelvis
    • 2018-05-11 CT - abdomen
      • S/P hysterectomy.
      • Relative dirty mesentery fat plane, post-op change?
      • Loculated fluid density in right obturator region, suspected lymphocele or seroma, suggest follow up study.
    • 2018-05-11 Transvaginal Ultrasonography
      • No obvious uterine or ovarian lesion
    • 2018-04-18 Patho - laparoscopic vaginal total hysterectomy (LAVH), Level VI
      • Uterus, endometrium, laparoscopic vaginal total hysterectomy (LAVH) — Endometrioid adenocarcinoma, grade 1
      • Uterus, myometrium, laparoscopic vaginal total hysterectomy (LAVH) — Endometrioid adenocarcinoma, invading >1/2 of the thickness of the myometrium.
      • Uterus, cervix, laparoscopic vaginal total hysterectomy (LAVH) — Free.
      • Ovaries and fallopian tubes, bilateral, laparosocpic salpingo-oophorectomy (BSO) — Free
      • Lymph node, bilateral pelvic, dissection (BPLND) — Free (0/25)
      • Omentum, omentectomy — Free (with one lymph node free of malignancy 0/1)
      • AJCC 8th edition Pathology stage: pT1bN0 (if cM0); pStage: IB.
      • S2018-05404: ER (+, 90%), PR (+, 90%)
    • 2018-04-14 MRI - pelvis
      • Imaging Report Form for Endometrial Carcinoma
      • Impression:
        • Endometrial malignancy, cstage T1bN0Mx.
        • Right obturator lymph node, suggest follow up.
    • 2018-04-03 Surgical pathology Level IV
      • Uterus, endometrium, D&C — Adenocarcinoa with squamous metaplasia.
      • IHC: ER (+, 90%), PR (+, 90%), p40 (-), p16 (+, 70%), vimentin (+, 80%).
    • 2018-04-02 Gynecologic ultrasonography
      • Suspected endometrial hyperplasia
  • consultation
    • 2022-05-04 Obstetrics and Gynecology
      • Q
        • poor appetite after traffic accident in Feburary
        • diarrhea, nausea for 2 weeks
        • periumbilical fullness for 2 weeks
        • EGD at LMD last week: GERD
        • abdominal sono at LMD on 5/2: ascites
        • PH: Malignant neoplasm of endometrium S/P hysterectomy, R/T
        • Allergy: NKA
      • A
        • findings
          • a case of endometrial cancer post staging surgery (ATH + BSO + BPLND + omentectomy) + radiotherapy in 2018.
          • post op course was smooth without recurrence, checked by CT scan, sonar and tumor marker until 2022/2
          • c/o abdominal distension, poor appetite for 2 weeks (c/o: complaint of)
          • no fever nor pain
          • CA125: 15 -> 460 elevated
          • GYN sonar: ascites > 1000 c.c
          • PV – vaginal stump no mass palpated, seemed free
          • no bleeding
        • Imp
          • ascites,
          • suspected cancer recurrence
        • Suggestion:
          • consider to arrange abdominal tapping (+ send ascites cytology) if indicated
          • symptom treatment with gascon, etc
          • please arrange abdominal CT scan
          • scheduled 20220509 W1 GYN OPD for further Tx
  • surgical operation
    • 2022-05-25
      • Operation
        • Laparoscopic exploration
      • Finding
        • Massive turbid ascites, > 4000cc
        • Multiple peritoneal seedings, compatible with carcinomatosis
        • Culture: ascites*1
    • 2018-04-17
      • Diagnosis
        • endometrial cancer (adenocarcinoma)
      • PCS
        • 80424B
      • Finding
        • Uterus: enlarged, 12x10x7cm
        • endometrium – thickened, soft necrotic tissues at fundus; EM cancer cells likely
        • myometrium – seemed invaded by cancer
        • cervix eroded
        • bil adnexa: normal-looking, seemed free of cancer invasion
        • omentum, appendix, bowels: seemed free of cancer invasion
        • CDS: no fluid (send ascites washing cytology) but severe pelvic bowel adhesion (due to previous vertival laparotomy?) was noted between ant peritoneum, left pelvis and bowels; between uterus and ant bladder s/p LSC adhesiolysis
        • A 7mm JP drain was placed in CDS
    • 2018-04-02
      • Diagnosis
        • Suspected endometrial hyperplasia or cancer – EM 2.43cm
      • PCS
        • 80423B
      • Finding
        • Under IVGA, Hysteroscopic endometrial curettage were done.
        • Thickened endometrium noted with a lot of soft necrotic tissues, suspected endometrial hyperplasia or cancer
  • chemoimmunotherapy
    • 2022-11-09 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-10-26 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-10-19 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-10-05 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-09-28 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-09-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 90min
    • 2022-09-07 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 90min
    • 2022-08-24 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-08-17 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-08-04 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-07-28 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-07-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-07-08 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-06-21 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-06-14 - gemcitabine 800mg/m2 1250mg 30min + cisplatin 20mg/m2 30mg 24hr

==========

2022-12-02

  • It should be noted that both serum creatinine and BUN increased 50% in the last two weeks (Cre 1.76 mg/dL 2022-11-30 <- 1.18 mg/dL 2022-11-16; BUN 33 mg/dL 2022-11-30 <- 20 mg/dL 2022-11-16), as well as bilirubin total exceeded 6 x ULN (6.95 mg/dL 2022-11-30).

  • 2022-11-30 eGFR 31.2

    • gemcitabine for patients with altered kidney function:
      • CrCl >= 30 mL/minute: IV: No dosage adjustment necessary (Cetina 2004; Delaloge 2004; Li 2007; Lichtman 2007; Venook 2000).
      • CrCl <30 mL/minute: IV: No dosage adjustment necessary. However, risk of hematologic toxicity may be increased in these patients, which may require gemcitabine dose modification (Cetina 2004; Li 2007; Lichtman 2007; Mir 2005; Tanji 2013; Venook 2000).
    • nab-paclitaxel for patients with altered kidney function:
      • CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (insufficient data).
  • 2022-11-30 bilirubin total 6.95 mg/dL, ALT 442 U/L, AST 342 U/L

    • gemcitabine for patients with hepatic Impairment - there are no dosage adjustments provided in the manufacturer’s labeling. The following adjustments have been reported:
      • Transaminases elevated (with normal bilirubin): No dosage adjustment necessary (Venook 2000).
      • Serum bilirubin > 1.6 mg/dL: Use initial dose of 800 mg/m2; may escalate if tolerated (Ecklund 2005; Floyd 2006; Venook 2000).
      • Dosage adjustment for hepatotoxicity during treatment: Discontinue if severe hepatotoxicity occurs during gemcitabine treatment.
    • nab-paclitaxel for patients with hepatic Impairment
      • Not recommended in case of AST > 10x ULN or bilirubin > 5x ULN
  • It is suggested to ensure that the patient’s kidney and liver function are in good condition prior to the chemotherapy.

2022-07-29

  • Tumor markers
    • CEA
      • 2022-07-26 5.21 ng/mL
      • 2022-05-02 3.10 ng/mL
      • 2022-01-24 1.96 ng/mL
      • 2021-10-25 1.84 ng/mL
    • CA125
      • 2022-07-26 788.2 U/mL
      • 2022-05-02 460.8 U/mL
      • 2022-01-24 15.1 U/mL
      • 2021-10-25 5.8 U/mL
      • 2021-07-26 5.5 U/mL
      • 2021-04-26 3.5 U/mL
    • CA199
      • 2022-07-26 12024.11 U/mL
      • 2022-05-23 >19680.00 U/mL
      • 2020-04-13 23.72 U/mL
  • In recent months, tumor markers have trended upward. The current regimen has been used to treat patients since mid-June 2022 (still less than 2 months).
  • FOLFIRINOX vs Gemtabine plus Nab-Paclitaxel, there is disagreement among studies regarding the choice between the two. references:
    • Klein-Brill A, Amar-Farkash S, Lawrence G, Collisson EA, Aran D. Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022;5(6):e2216199. doi:10.1001/jamanetworkopen.2022.16199
    • Riedl JM, Posch F, Horvath L, et al. Gemcitabine/nab-Paclitaxel versus FOLFIRINOX for palliative first-line treatment of advanced pancreatic cancer: A propensity score analysis. Eur J Cancer. 2021;151:3-13. doi:10.1016/j.ejca.2021.03.040
    • Chun JW, Lee SH, Kim JS, et al. Comparison between FOLFIRINOX and gemcitabine plus nab-paclitaxel including sequential treatment for metastatic pancreatic cancer: a propensity score matching approach. BMC Cancer. 2021;21(1):537. Published 2021 May 11. doi:10.1186/s12885-021-08277-7
    • Tahara J, Shimizu K, Otsuka N, Akao J, Takayama Y, Tokushige K. Gemcitabine plus nab-paclitaxel vs. FOLFIRINOX for patients with advanced pancreatic cancer. Cancer Chemother Pharmacol. 2018;82(2):245-250. doi:10.1007/s00280-018-3611-y

2022-07-06

  • No mutation test results were found for BRCA1/2 or PALB2. A change in the regimen from gemcitabine + cisplatin to gemcitabine + nab-paclitael has been made in late June 2022. Whereas FOLFINOX or modified FOLFINOX (not used in this case) should be limited to patients with an ECOG of 0 or 1.
  • There has been a low potassium level of 1.9 mmol/L on 2022-07-05. A KCl injection, oral potassium gluconate, and a spironolactone dose have been prescribed.

701450418

221201

  • exam findings
    • 2022-10-04 Pelvis and Bilat. Hip. Lat.
      • Narrowed joint or discal space with bony sclerosis but without acute fracture, bone destruction or dislocation.
    • 2022-10-03 CXR
      • Left pleural effusion. A LLL tumor mass.
      • No cardiomegaly by cardiac/thoracic ratio.
      • Post operative appearance in or at the area of TL spine.
      • Presence of numerous small miliary-like lesions in bilateral lung fields, metastases should be rule out.
    • 2022-09-28 T-L spine AP + Lat.
      • Presence of spondylolisthesis at L4/5, grade I.
      • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s) L2.
      • S/P posterior longitudinal transpedicular spine screws and rods fixation.
    • 2022-09-27 EGFR mutation
      • A deleteion was detected at exon 19 of EGFR gene in this specimen.
      • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
    • 2022-09-29 PD-L1 (22C3)
      • Tumor Proportion Score (TPS) assessment: TPS < 1%
    • 2022-09-29 PD-L1 28-8 IHC
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percent of PD-L1 expression in tumor cells (TC): < 1%
    • 2022-08-11 PD-L1 (SP142)
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana) - S2022-16383
        • Tumor type: adenocarcinoma
        • Tumor location: lung
        • Testing assay: SP142 Assay (Ventana)
        • Testing platform: BenchMark XT
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
        • Control slide result: Pass,
        • Adequate tumor cells present (>=50 viable tumor cells): Yes,
      • Result:
        • Tumor cell (TC) staining assessment: TC category: TC < 1%
        • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-09-26 Patho - lung transbronchial biopsy
      • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
      • Sections show neoplastic acinar glandular cells infiltrating in a fibrotic stroma.
    • 2022-09-21 Whole body PET scan
      • Glucose-hypermetabolic lesions in the left upper and lower lungs with pleura involvement, highly suspected lung cancer with lung to lung mets and malignant pleural effusion.
      • Glucose hypermetabolic lesions in bilateral mediastinal and right pulmonary hilar lymph nodes, highly suspected lung cancer with regional lymph nodes metastases.
      • Increased uptake of FDG in the right adrenal gland, L2 spine, and left frontal skull, highly suspected lung cancer with multiple distant metastases.
      • Left lung cancer with lung to lung, bilateral mediastinal and right pulmonary hilar lymph nodes, right adrenal gland, L2 spine, and left frontal skull metastases, cT4N3M1c, stage IVB (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2022-09-20 MRI - brain
      • No obvious brain or intracranial nodule or metastasis 2. r/o Focal left frontal skull metastasis.
  • consultation
    • 2022-11-30 Rehabilitation
      • A
        • Assessment
          • Left lower lobe lung cancer with bilateral lung to lung meta, mediastinal lymphadenopathy, lumbar spine pathological fracture, right adrenal meta and probably liver meta
          • Multiple bone metastases with L2 pathological fracture
        • Plan
          • Rehabilitation programs: Bedside PT, OT rehabilitation programs; apply ant. AFO for left drop foot
          • Goal: improve ADL, muscle power and endurance
    • 2022-11-09 Rehabilitation
      • Assessment
        • Malignant neoplasm of lower lobe, left bronchus or lung
        • Secondary malignant neoplasm of bone
        • Left lung adenocarcinoma with pathology fracture of L2 status post L2-L3 laminectomy, fixation and postero-lateral spinal fusion on 2022/09/12 s/p TKI with Afatinib from 2022/10/25
        • Chronic viral hepatitis B without delta-agent
      • Plan
        • Rehabilitation programs: Bedside PT and OT rehabilitation programs
        • Goal: improved ADL and muscle power, ambulate with device under supervision
    • 2022-11-10 Dermatology
      • Q
        • This 48-year-old woman patient is a csae of Left lung adenocarcinoma with pathology fracture of L2 status post L2-L3 laminectomy, fixation and postero-lateral spinal fusion on 2022/09/12 s/p TKI with Afatinib from 2022/10/25. This time, for whole body skin red rash after TKI. Now, for evaluate whole body red rash therapy. Thank you.
      • A
        • The patient had sufferred from exfoliative reddish plaques with scales over face and mutiple pustular lesions over chest/back.
        • Under the impression of seborrheic dermatitis (immunocompressed state?) and follculitis on the trunk.
        • The following sugeetion:
          • Oral doxycycline and broen-C 1# bid po for 5 days.
          • For face, Free gel 1 tube topical bid use over large area first and consider Rinderon-V cream 2 tube topical bid over reddish itchy area.
          • For trunk, Clindamycin gel 1 tube topical bid use on the pustular lesions.
    • 2022-09-23 Oral and Maxillofacial Surgery
      • Q
        • This 48 years old female patient was diagnosed of lung cancer with bone metastatic. She had underwent L2, L3 laminectomy and fixation and posterior-lateral fusion cause by L2 pathological fracture with spinal stenosis. We had keep lung cancer treatment, and prepare use denosumab. We need your professional evaluation and recommendation for dental evaluation. Thank you very much for your time!
      • A
        • O:
          • Full mouth chronic periodontitis
          • Fair oral hygiene.
          • No visible caries was notd.
        • P:
          • Explain the finding to the patient.
          • Home care instrcution.
          • OPD follow up
    • 2022-09-21 Hemato-Oncology
      • A
        • Impression:
          • LEFT LOWER LOBE lung cancer with bilateral lung to lung meta. Mediastinal lymphadenopathy, lumbar spine pathological fracture, right adrenal meta and probably liver meta, cT4N3M1c, StageIVB
        • Suggestion:
          • family meeting has been arranged on 20220922 18:00
          • Arrange Chest CT guide biopsy for EGFR gene mutation test, PD-L1
          • May check Anti Hbc, HbsAg, Anti-HCV
          • Consult oral surgery for denal evaluation (prepare use denosumab which has been associated with osteonecrosis of the jaws)
          • We woukd like to follow up this case, thanks for your consultation. If there is any problem, please feel free to let us know.
    • 2022-09-14 Rehabilitation
      • A
        • Assessment
          • suspected left L1-L3 radiculopathy due to multiple bone metastases with L2 pathological fracture
        • Plan
          • Keep pain control medication
          • suggest waist support when sitting up
          • futher L-spine image could be follow up if pain exaggerates
  • chemoimmunotherapy
    • 2022-10-25 ~ 2022-11-08 Giotrif (afatinib 30mg) 1# QDAC

[note]

  • Giotrif (afatinib 30mg) nasogastric tube feeding - Alternative Methods of Administration (package insert 20210526)
    • If dosing of whole tablets is not possible, GIOTRIF tablets can be dispersed in approximately 100 mL of noncarbonated drinking water. No other liquids should be used. The tablet should be dropped into the water without crushing it, and stirred occasionally until the tablet is broken up into very small particles (approximately 15 minutes). The dispersion should be consumed immediately. The glass should be rinsed with approximately 100 mL of water which should also be consumed. The dispersion can also be administered through a gastric tube.

[assessment]

  • In accordance with NCCN recommendations for NSCLC (guideline version 5.2022), osimertinib is preferred for patients with EGFR exon 19 deletion, along with erlotinib, afatinib, and dacomitinib.
  • Giotrif (afatinib) was prescribed to the patient during 2022-10-25 and 2022-11-08.
  • As of 2022-11-30, there were no extrem results in the lab test, and the patient’s vital signs remained stable.
  • There is no issue with the active prescription.

700341408

221130

{This 80-year-old man patient is a case of Diffuse large B-cell lymphoma, Non-GCB type, at the right maxillary gingiva and tuberosity, Ki-67 index >95%, Lugano stage II, IPI score: 1, Low risk group, PS:0}

  • past history
    • Hyperlipidemia
    • Arrythmia
    • Coronary artery disease, with middle left anterior descending artery myocardial bridge
  • operation history:
    • s/p appendectomy
    • pituitary macroadenoma s/p transsphenoisia reemoval of pituitary adenoma on 20131105.
    • tumor excision over mesenchymal origin tumor over left buttock on 20210304 showed benign fibrotic cystic wall tissue  
  • family history
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.
  • exam findings
    • 2022-11-29 ECG
      • Sinus tachycardia
      • Nonspecific ST abnormality
    • 2022-11-24, -11-14, -10-27, -08-17 CXR
      • Atherosclerotic change of aortic arch
    • 2022-11-16 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (58 - 16) / 58 = 72.41%
        • M-mode (Teichholz) = 72
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with mild AR; prominent posterior mitral annulus calcification with mild MR; moderate TR; mild PR.
    • 2022-11-03 SONO - abdomen
      • Hepatic calcification, right lobe
      • Renal cysts, both
      • Renal lesion, LK, favor angiomyolipoma
    • 2022-11-02 MRI - nasopharynx
      • Indication: He was just proved lymphoma in his mouth. He was referred by a local dentist because of an oral tumor. According to his statement, he notes this mass aroud one month ago. He has history of pitutary problem, hypertension for years.
      • Findings
        • metallic artifacts in the oral cavity
        • mild mucosal thickening in the bilateral maxilalry sinuses.
        • mucasal thickening in the upper esophagus. Please correlate with other image modality.
        • a multi-lobulated heterogeneous enhancing tumor, about 33mm, in the head of the right medial pterygoid muscle, inferior aspect of the maxillary sinus and right upper buccogingival mucosa.
        • no neck LAP.
      • IMP:
        • a multi-lobulated heterogeneous enhancing tumor, about 33mm, in the head of the right medial pterygoid muscle, inferior aspect of the maxillary sinus and right upper buccogingival mucosa.
        • mucosal thickening in the upper esophagus.
    • 2022-09-29 Sonography - thyroid gland
      • Normal size of the thyroid gland.
      • A heterogenic nodule (0.47x0.78cm) in left thyroid gland.
    • 2022-09-20 Myocardial perfusion SPECT with persantin
      • Probably mild myocardial ischemia at the lateral wall.
    • 2022-09-19 ECG
      • Sinus bradycardia
      • T wave abnormality, consider anterolateral ischemia
    • 2022-09-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (49.8 - 11.9) / 49.8 = 76.10%
        • M-mode (Teichholz) = 76.1
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild to moderate MR and TR, mild AR and PR
      • Mildly thick IVS and LVPW
    • 2022-09-03 ECG
      • Atrial flutter with variable A-V block
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-09-03 ECG
      • Possible atrial flutter with 2:1 AV conduction
      • ST & T wave abnormality, consider anterolateral ischemia
      • Abnormal ECG
    • 2022-08-18 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (67.5 - 15.3) / 67.5 = 77.33%
        • M-mode (Teichholz) = 77.3
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, TR
    • 2022-08-16 Whole body PET scan
      • Glucose hypermetabolism in a focal area involving the right maxillary sinus, right nasal cavity, soft palate and right oropharynx, in the left maxillary sinus and in two left submandibular lymph nodes, compatible with lymphoma.
      • Glucose hypermetabolism in a focal area in the pituitary fossa, compatible with a macroadenoma. However, please correlate with other clinical finidngs for further evaluation and to rule out other possibilities.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • 2022-08-02 Patho - gingival/oral mucosa biopsy
      • Pathologic diagnosis
        • Oral cavity, right maxillary gingiva, incisional biopsy — Diffuse large B-cell lymphoma, Non-GCB
      • Macroscopic description
        • Operation procedure: incisional biopsy
        • Topology: Oral cavity, right maxillary gingiva
        • Specimen size and number: 2 pieces, up to 1.2x 0.8x 0.4 cm
      • Microscopic examination
        • Histology type: B-cell neoplasms - Diffuse large B-cell lymphoma (any subtype)
        • Immunohistochemical stain profiles: C-myc(+, >40%), CD3(-), CD20(+), CD10(-), CD56(-), Cyclin D1(-), Bcl-6(+),Bcl-2(+),MUM-1(+), CK(-), Ki-67 index: > 95%.
    • 2022-05-26 SONO - abdomen
      • Diagnosis
        • Hepatic cysts, bilateral lobes
        • Fatty infiltration of pancreas
        • Pancreatic cystic lesion, neck-body
      • Suggestion
        • Hepatic lesion may be masked by fatty liver background
    • 2022-05-18 MRI - sella
      • Indication: for follow up brain tumor. patient had diplopia pituitary macroadenoma, s/p resection 7 yrs ago. residual tumor enlarging in size recently. S: for SRS arrangement. check prolactin level, consider surgical intervention. PATIENT REQUEST FOR STEREOTACTIC RADIOSURGERY. for follow up image study.
      • Findings
        • The high SI on T1WI in the posterior lobe of the pituitary gland was preserved.
        • a pituitary gland tumor, about 15mm x 16mm x 17mm, in the pituitary fossa and suprasellar cistern. The pituitary stalk was elevated. The lesion revealed low SI on T1WI and heterogeneous high SI on T2WI. Tumor invasion to the left cavernous sinus was noted. Tumor encasement of the left caverous ICA was noted.
        • unremarkable change in the bony middle cranial fossa
        • some white matter gliosis in the bilateral frontal and parietal lobes.
      • IMP: pituitary gland macroadenoma with invasion to the left cavernous sinus and tumor encasement of the left cavernous ICA.
    • 2022-04-14 Sonography - thyroid gland
      • Normal size of the thyroid gland.
      • Some hypoechoic nodules (0.26x0.36cm, 0.41x0.69cm) in left thyroid gland.
  • consultation
    • 2022-09-03 Cardiology
      • A
        • O
          • ECG: suspected atrial flutter or atrial tachycardia (less than 24 hours)
          • CxR: RLL infiltration; L’t pleural effusion
          • SBP 140 mmHG;
          • PH of thyroxine supplement;
        • Suggestion
          • Amiodarone infusion for possibly atrial flutter; concor 0.5# st and qd if SBP > 110 mmHg.
          • F/U Tn-I level; if further elevation, may admit to ICU for close monitoring.
          • Check thyroid function.
          • Infection survey and empiric antibiotic for suspected pneumonia.
          • Arrange 2D echo after admission.
    • 2021-01-14 Cardiology
      • Q
        • Hx of myocadial bridge
      • A
        • I was consulted for elevated troponin I of a 79-year-old man who visited to ED acute onset of chest pain relieved by SL NTG this morning.
        • S
          • No cold sweating and radiation pain.
          • Episodes of chest pain for 4 times in recent months.
          • Hx of myocardial bridge in 2017.
        • O
          • 2021/01/14 07:12 hs-Troponin I = 16.5 pg/mL;
          • 2021/01/14 09:45 hs-Troponin I = 71.8 pg/mL;
          • No chest pain on visit
          • No signicant murmur, no pitting edema
          • EKG: TWI from V1-6 on admission to ED, then resolution of TWI at V1-2, persistent TWI at V4-6
          • Beside cardiace echo: normal wall motion.
        • Impression:
          • Elevated troponin I due to myocardial bridge is more likely
          • Angina pectoris due to myocardial bridge
        • Suggestion:
          • Regular medication for myocardial bridge with angina pectoris is suggested. Please prescribe Diltiazem (30) 0.5# BID and Coxine 0.5# BID PO (may hold Diltiazem if SBP <90mmHg or dizziness)
          • Option for cardiac catheterization was explained to the patient and his wife; if they want to recieve cardiac cathetertization, please call me (before noon).
          • The patient was informed to observe the symptoms and also informed about the warning sign.
          • CV OPD follow up if they choose to discharge
  • chemoimmunotherapy (R-mCHOP)
    • 2022-11-17 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
    • 2022-10-17 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
    • 2022-09-21 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
    • 2022-08-26 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5

[assessment]

  • WBC 410/uL 2022-11-30 <- 580/uL 2022-11-29. For (febrile) neutropenia, filgrastim and cefepime have been used. The results of the blood culture are pending.
  • The heart rate is volatile (63 ~ 122 beat/minute), 2022-11-29 ECG showed sinus tachycardia and nonspecific ST abnormality. Please continue to monitor the hemodynamic parameters.

701125676

221130

{Esophageal cancer, cT2N2Mo stage III, Port-A insertion at left cephalic vein on 20220922, jejunostomy tube insertion at abdomen on 20220922}

  • lab data
    • 2022-09-16 HBsAg High Reactive
    • 2022-09-16 HBsAg Value 551.57 IU/mL
    • 2022-09-16 Anti-HBc Reactive
    • 2022-09-16 Anti-HBc-Value 8.41 S/CO
    • 2022-09-16 Anti-HCV Nonreactive
    • 2022-09-16 Anti-HCV Value 0.07 S/CO
  • exam finding
    • 2022-11-02 Tc-99m MDP whole body bone scan with SPECT
      • Increased activity in the left iliac crest and bilateral acetabula, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, sacrum, bilateral shoulders, and S-I joints.
    • 2022-11-01, -10-03, -09-27, -09-21 Abdomen - standing (diaphragm)
      • S/P compression plate and screws fixation at right ilium and right acetabulum.
    • 2022-09-16 CT - chest
      • Indication: Malignant neoplasm of esophagus, unspecified.
        • He was referred on account of due to difficult of swallowing and chest dyscomfort for about one week. PES and biopsy showed esophageal cancer (at New Taipei City Hospital)
      • Findings
        • Chest:
          • Dilated upper and middle third esophagus with narrowing at lower third extending to EG junction is found.
          • Enlarged lymph nodes are found at gastric cardiac region. (n=5)
          • Paraseptal Emphysematous change over both apical lungs is found.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • Lower third esophageal cancer with regional lymphadenopathy
      • Imaging Report Form for Esophageal Carcinoma
        • Impression (Imaging stage): cT2N2M0, Stage III
    • 2022-09-15 CXR (New Taipei City Hospital SanChong Branch)
      • No cardiomegaly.
      • Prominent bronchovasculature over bilateral lung fields.
      • No blunting of bilateral costo-phrenic angles.
    • 2022-09-13 Pathology (New Taipei City Hospital SanChong Branch)
      • Diagnosis
        • S22-4658 Esophago-cardia junction, endoscopic biopsies, Adenocarcinoma, moderate to poorly differentiation.
      • MACROSCOPIC:
        • Quantity: one tissue fragments, 0.5 x 0.2 x 0.2 cm in size. All for section.
      • MICROSCOPIC:
        • Histological diagnosis: Adenocarcinoma.
        • High grade dysplasia (including severe dysplasia and carcinoma in situ): present.
        • Invasive carcinoma: present.
        • Lymphovascular invasion: absent.
        • Histologic grade: G2, moderately to poorly differentiated with focal individually cells infiltration throughout muscularis mucosa.
        • Comment: No Helicobactor bacillus found on Giemsa stain.
        • Immunohistochemical stains: the tumor cells showed cytoplasmic stains for CK7 and nuclear stain for STAB2.
    • 2022-09-17 UGI panendoscopy (New Taipei City Hospital SanChong Branch)
      • swelling and irregular mucosa which was easily contact bleeding was found at EC junction post biopsy was taken.
    • 2018-05-05 SONO - abdomen (Nephrology)
      • Left parapelvic renal cyst.
      • Suspected left small renal stone.
  • consultation
    • 2022-11-01 Dermatology
      • Q
        • for skin rash at the face.
        • This time, he is admitted for C2 CCRT with PF on 2022/11/01, and the skin rash at the face noted, so we need your help, thanks a lot!!
      • A
        • The patient had sufferred from bilateral facial reddish flush/papules with fine scales on the nasalfold and cheek area.
        • Under the impression of seborrheic dermatitis.
        • The following sugeetion:
          • Free gel 1 tube topical bid use for facial erythema region
          • If severe itchy sensation, consider futisone cream 1 tube topical bid PRN use on these itchy area.
    • 2022-09-22 Radiatoin Oncology
      • A
        • S:
          • For preoperative CCRT due to low third esophageal carcinoma.
          • PI: The patient suffered from dysphagia and chest discomfort since 2022-8. He went to New Taipei City Hospital SanChong Branch for help. The Panendoscopy and biopsy showed esophageal cancer. Under the personal reason, he was referred to our Hematology Oncology. Followed-up chest CT (Sep 16,22) showed Lower third esophageal cancer with regional lymphadenopathy cT2N2M0, stage III.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (quit).
          • Personal Hx: DM(-); HTN(-)
          • Allergy(-)
          • Previous RT Hx: (-)
        • O:
          • ECOG: 0
          • PE: neck and bil SCF: neg.
          • UGI panendoscopy (2022-09-07, New Taipei City Hospital SanChong Branch): swelling and irregular mucosa which was easily contact bleeding was found at EC junction post biopsy was taken.
          • Pathology (2022-09-13, New Taipei City Hospital SanChong Branch): S22-4658 Esophago-cardia junction, endoscopic biopsies, Adenocarcinoma, moderate to poorly differentiation. MACROSCOPIC: Quantity: one tissue fragments, 0.5 x 0.2 x 0.2 cm in size. All for section. MICROSCOPIC: Histological diagnosis: Adenocarcinoma. High grade dysplasia (including severe dysplasia and carcinoma in situ): present. Invasive carcinoma: present. Lymphovascular invasion: absent. Histologic grade: G2, moderately to poorly differentiated with focal individually cells infiltration throughout muscularis mucosa. Comment: No Helicobactor bacillus found on Giemsa stain. Immunohistochemical stains: the tumor cells showed cytoplasmic stains for CK7 and nuclear stain for STAB2.
          • CXR (2022-09-15, New Taipei City Hospital SanChong Branch): No cardiomegaly. Prominent bronchovasculature over bilateral lung fields. No blunting of bilateral costo-phrenic angles.
          • CT scan of lung (2022-09-16): Lower third esophageal cancer with regional lymphadenopathy, AJCC stage cT2N2M0 (stage III).
        • A:
          • Adenocarcinoma, moderate to poorly differentiation of the low third esophagus to EG junction, AJCC stage cT2N2M0 (stage III).
        • P: Radiotherapy is indicated for this patient with the following indicators: AJCC stage cT2N2M0 (stage III)
          • Goal: curative
          • Treatment target and volume: esophageal tumor, periphjeral involved, to regional involved nodal area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 4500cGy/25 fractions of the esophageal tumor, periphjeral involved, to regional involved nodal area, and 5040cGy/28 fractions of the esophageal tumor and involved nodal lesions.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-9-26.
  • radiotherapy
    • 2022-10-03 ~ 2022-11-17 - 4500cGy/25 fractions (15MV photon) of the esophageal tumor, periphjeral involved, to regional involved nodal, and 5040cGy/28 fractions of the reduced area.
  • chemoimmunotherapy
    • 2022-11-29 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1600mg 24hr D1-D4 (PF, CCRT)
    • 2022-11-03 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1650mg 24hr D1-D4 (PF, CCRT)
    • 2022-10-03 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1700mg 24hr D1-D4 (PF, CCRT)

[assessment]

  • In one month, there has been a substantial loss of weight, almost ten kilograms (52.3kg 2022-11-29 <- 61.1kg 2022-10.27).
  • A low serum creatinine level (0.68mg/dL 2022-11-29) was noted. Creatinine generation could be reduced in the setting of low skeletal muscle mass.
  • It is recommended that intake be increased.
  • In terms of the active prescription, there is no problem.

700021863

221128

{Protocol: Capsule suspension preparation and NG tube dispensing procedures for Xtandi (enzalutamide, 160mg dose)}

The following in-situ oral dosing syringe suspension preparation and NG tube dispensing procedures were identified as being facile and which essentially eliminate human exposure to capsule components:

Utensils: Tweezers, medical grade scissors, 2-3mL oral dosing syringe, 20mL oral dosing syringe, NG tube, and one 2-3 oz (60-90 mL) glass or plastic dosing container (e.g., beaker or med cup).

Materials: Ethanol, 95%, Deionized water, 4x40mg enzalutamide capsules

  • Prepare 40-50mL of 90% v/v ethanol:water. Transfer 30mL to a container. Cover if not used immediately. Use as reservoir for subsequent steps.
  • Swipe-clean the dosing container, tweezers and scissors with alcohol wipes.
  • Using tweezers and scissors carefully cut a small vent, ~2mm long, through a soft gel capsule wall-just enough to vent internal pressure. Note: cut vent over dosing cup since some material may flow out of the vent hole. Place vented capsule in dosing cup. Repeat for remaining 3 capsules.
  • Using tweezers and scissors, slowly cut each capsule in half laterally. Allow capsule contents (enzalutamide in Labrasol) to empty into dosing cup (fill material flows out easily). Repeat for all capsules. Note: all 8 capsule shell pieces and fill contents will be in in the dosing cup.
  • Hold each capsule shell piece with tweezers and rinse the inside and outside into the dosing cup using 90% ethanol. Use 1-2mL per capsule half (2-3mL syringe). Discard rinsed capsule shells.
  • Withdraw 10mL of ethanol solution and rinse the tweezers and scissors into the dosing cup.
  • Withdraw and dispense solution back into dosing cup at least 5 times to ensure a homogeneous mixture.
  • Withdraw the solution into the dosing syringe.
  • Slowly dispense through the NG tube.
  • Withdraw the remaining ~10mL of 90% ethanol, rinse dosing cup, withdraw into dosing syringe, cap and shake, and dose through the NG tube. Flush tube with 6mL of water.

Please prepare two vials of 99.5% alcohol (drug code ‘CALCO01’), add one ml of purified water, take eight ml of the solution to dissolve one split capsule of 40 mg Xtandi, and tube feed this solution containing enzalutamide with prandial.

701321501

221125

{Mesenchymal chondrosarcoma, high grade}

  • exam finding
    • 2022-11-17, -10-20, -09-22, -08-22, -07-21 Sinoscopy
      • Right maxillary sinus sarcoma s/p op on 2022-03-30, no evidence of tumor
    • 2022-11-01 MRI - nasopharynx
      • Clinical information: Right maxillary sinus sarcoma s/p Right total Maxillectomy on 2022-03-30, patho: high grade mesenchymal chondrosarcoma, pT4aN0M0, Grade 3
      • Findings:
        • The current study was compared to the prior one obtained on 2022/08/09.
        • Known a case of right maxillary sinus sarcoma S/P operation and flap reconstruction. Progression of abnormal enhancing lesion over right face, near the reconstructive area. Suggest tissue proof to rule out recurrence.
        • Paranasal sinusitis.
        • The right parotid gland enhance as before. It is consistent with post-radiation inflammation.
        • S/P resection of right submandibular gland.
    • 2022-08-09 MRI - nasopharynx
      • Post total right maxillectomy, no obvious residual tumor or mass. No neck LAP.
    • 2022-07-07 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 25) / 87 = 71.26%
        • M-mode (Teichholz) = 70
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, and trivial TR
      • Preserved RV systolic function
    • 2022-06-09, 2022-05-26, 2022-05-12, 2022-04-28 Sinoscopy
      • Right maxillary sinus sarcoma s/p op on 2022-03-30
    • 2022-05-26 Hearing Test
      • Tymp:
        • R’t type B; L’t type As.
      • ART:
        • R’t and L’t contra absent.
      • PTA
        • Reliability FAIR
        • Average RE 60 dB HL; LE 23 dB HL.
        • R’t moderate to profound MHL.
        • L’t normal to moderate HL.
        • (masking dilemma)
    • 2022-04-21 Nasopharyngoscopy
      • Right maxillary sinus sarcoma s/p op on 2022-03-30
    • 2022-03-31 Patho - oral cancer (wide excision + lymph node)
      • Pathologic diagnosis
        • Maxillary sinus, right, total maxillectomy — Mesenchymal chondrosarcoma, high grade
        • Lymph nodes, right neck, selective neck dissection — Negative for malignancy (0/31)
        • Submandibular gland, right, neck dissection — No remakable change
        • Pathology stage: pT1N0; Stage IIA if cM0
      • Macroscopic examination
        • Surgical Procedure(s): Total maxillectomy + right selective neck dissection
        • Specimen Type:
          • Main location: Maxillary sinus
          • Lymph node dissection: Yes, including right neck level I, level II, and level III
        • Specimen Integrity: intact
        • Specimen Size: 6.2 x 5.5 x 5.4 cm
        • Tumor Site: Maxillary sinus; Laterality: Right
        • Tumor Focality: Single focus
        • Tumor Size: 6.0 x 4.5 x 4.0 cm, 0.5 cm from posterior margin
        • Mucosal Surface : Ulcerated
        • Gross Tumor Extension: Tumor invades submucosa
        • Representative parts are taken for section and labeled: A1-A2 = level I LN + submandibular gland, B = level II LNs, C = level III LNs, D = pterygoid plate, E = zygoma with soft tissue, F1 = tumor + posterior margin, A2 = tumor + lateral margin, F3 = tumor + upper margin, F4-F10 = tumor, G = posterior nasal margin, H = temporalis margin.
        • F2022-00138FSA1 = post. nasal margin, post. orbital floor and post. oral floor margin; FSA2 = lat. margin, masseter margin, and tempolais margin; FSA3 = orbital lat. margin and lat pterygoid margin; FSA4 = med. pterygoid margin and tissue near zygoma; FSE = posterior nasal margin (re-excision).
      • Microscopic examination
        • Histologic Type: Mesenchymal chondrosarcoma
        • Histologic Grade: G3 (poorly differentiated, high grade)
        • Mitotic Rate: 6/10 high power fields
        • Necrosis: Present (10%)
        • Microscopic Tumor Extension: To submucosa
        • Margins: Margins free, Distance from closest margin: 0.5 cm (posterior margin)
        • Lymph-Vascular Invasion: Not identified
        • Perineural Invasion: Not identified
        • Neck Lymph Nodes, Right: Negative (0/31)
          • Number of LN examined: 11 (level I), 9 (level II), and 11 (level III)
          • Number of LN metastasis: 0
        • Submandibular gland, right: Unremarkable and free of tumor
        • Pterygoid plate, right: Involved by tumor
        • Zygoma with soft tissue, right: Free of tumor
        • Post nasal margin, right: Free of tumor
        • Temporalis margin, right: Free of tumor
        • Post nasal margin and temporalis margin, received frozen section: Involved by tumor
        • Surgical margins received for frozen section, including post. orbital floor, post oral floor margin, lat margin, masseter margin, tempolais margin, orbital lat margin, lat pterygoid margin, med pterygoid margin, tissue near zygoma, and posterior nasal margin (re-excision): Free of tumor
    • 2022-03-30 Frozen section
      • Post. nasal margin #1, right, frozen section — Involved by tumor
      • Temporalis margin, right, frozen section — Favor inflammation but tumor involvement can not be excluded
      • Tissue near zygoma, right, frozen section — Favor inflammation
      • Post. orbital floor, post. oral floor margin, lat. margin, masseter margin, orbital lat. margin, lat. pterygoid margin, med. pterygoid margin; right, frozen section — Free of tumor
      • Posterior nasal margin #2, right, frozen section — Free of tumor
    • 2022-03-25 Nasopharyngoscopy
      • Right maxillary sinus sarcoma
    • 2022-03-22 SONO - abdomen
      • GB polyp
      • Pleural effusion, right
    • 2022-03-21 Whole body PET scan
      • Glucose hypermetabolism in the right maxillary sinus and adjacent facial soft tissue, compatible with the primary maxillary sarcoma. .
      • Glucose hypermetabolism in the left nasal cavity with left maxilla bone involvement, the nature is to be determined (another nasal cavity tumor or other nature ?), suggesting biopsy for further investigation.
      • Right maxillary sinus sarcoma, cTxN0M0; suspected left nasal cavity tumor, by this F-18 FDG PET scan.
    • 2022-03-18 CT - lung/mediastinum/pleura
      • Bilateral pleural effusion and lung partial collapse
      • suspected acute pancreatitis.
    • 2022-03-17 MRI - nasopharynx
      • Huge lobulated mass lesion (6.4cmx4.6cm) over right maxillary sinus with destruction of sinus walls, heterogeneous enhancement and cetral necrosis of this tumor. Highly suspect malignancy such as SCC or sarcomatous tumor.
      • Marked swollen change of right face and masticator space with subcutaneous fatty strandings.
    • 2022-03-15 Patho - gingival/oral mucosa biopsy
      • Oral cavity, right upper gingiva, biopsy — sarcoma
      • IHC: CK(-), Vimentin(+), SMA(focal +), CD34(-), CD56(-), and S-100(-). The Ki-67 is about 15%. The results are in favor of sarcoma. Please correlate with the clinical presentation and image study.
    • 2022-03-15 2D transthoracic echocardiography
      • Normal AV/MV with trivial MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, trivial TR, normal IVC size
    • 2022-03-14 CT - brain
      • IMP: Right maxillary sinus lesion as described.
      • DDX: malignancy, osteomyelitis, sinusitis.
    • 2022-03-14 ECG
      • Sinus tachycardia
      • Right superior axis deviation
  • consultation
    • 2022-04-12 Radiation Oncology
      • A: Mesenchymal chondrosarcoma, high grade, of the right maxillary sinus, stage pT1N0(cM0); Stage IIA, s/p operation (Rt. total Maxillectomy; Rt. selective neck dissection, level I~III; Tracheostomy; Tooth extraction of #46; free right anterolateral thigh flap resurfacing to the defect of right cheek, palate, and nasal cavity; reconstruction of right orbital bony frame with titanic microplates and screws).
      • P: Radiotherapy is indicated for this patient with the following indicators: margin involve and close (depend on HN tumor board conclusion).
        • Goal: curative
        • Treatment target and volume: right maxillary tumor bed area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 6000 ~ 6600cGy/30 ~33 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his mother. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-04-25.
      • HN tumor board (2022-04-15). RTC: at 2pm, 2022-04-15.
    • 2022-03-23 Oral and Maxillofacial Surgery
      • This is a 43 year-old male patient suffering from osteosarcoma of right maxilla and is scheduled for surgical intervention including right hemi-maxillectomy next week.
      • This time, we were consulted for pre-OP and pre-RT dental evaluation
      • O:
        • Radiographic findings:
          • Progressive destruction of right maxilla with root resorption of tooth 14 was noted.
          • Residual roots of tooth 46 was noted.
        • Full mouth poor oral hygiene with periodontitis
      • P:
        • Took panoramic film to evaluate full mouth condition
        • Explained the findings and treatment plan to the patient and his family
        • Suggest extraction of residual roots 46 during surgery.
        • Oral hygiene instruction.
    • 2022-03-16 Gastroenterology
      • S
        • According to the patient, no HBV history
      • O
        • AST: x, ALT: 18, Bil T: 0.78, ALP: x, r-GT: x, Cr: 0.79
        • HBsAg(-), Anti-HBc(+), Anti-HCV(-)
        • Abdominal echo: nil
      • Impression
        • Occult or resolved HBV infection
      • Suggestion
        • No NHI indication for HBV medication now; if patient needed chemotherapy or immunotherapy, please tell us
        • GI OPD follow up
    • 2022-03-15 Hemato-Oncology
      • A
        • Impression:
          • Right maxillary sinus lesion. DDX: malignancy, osteomyelitis, sinusitis.
        • Suggestion:
          • Please check EB V EA/NA IgA, SCC, LDH
          • Pending pathology and culture result
          • Treat sepsis as your expertise
          • We wound like to follow up this case, thanks for your consultation. If there is any problem, please feel free to let us known.
    • 2022-03-15 ENT
      • Granular tumor with pus discharge at right upper gingiva and hard palate was noted.
      • Malignant tumor of right maxillary sinus with oral cavity involvement was highly suspected.
      • Biopsy was done smoothly.
      • Please pursue the pathologic result.
    • 2022-03-14 Oral and Maxillofacial Surgery
      • S: My right face swelling and my upper right gingiva ozzing
      • O:
        • Right face swelling was noted
        • 15 16 17 missing with a mass over upper right gingiva, about 5x7 cm, ulcerative surface was noted
      • A:
        • Impression: SCC or osteosarcoma
      • P:
        • Physical exam and explain the finding to the patient
        • Please prescribe curam for infection control
        • Admission in MICU for infection control and arrange OPD follow up
  • surgical operation
    • 2022-06-20
      • Right grommet insertion
    • 2022-03-30
      • free right anterolateral thigh flap resurfacing to the defect of right cheek, palate, and nasal cavity
      • reconstruction of right orbital bony frame with titanic microplates and screws
    • 2022-03-30
      • Rt. total Maxillectomy
      • Rt. selective neck dissection, level I~III
      • Tracheostomy
      • Tooth extraction of #46
  • radiotherapy
    • 2022-04-29 ~ 2022-06-16
      • 4000cGy/20 fractions of the right maxillary tumor bed area,
      • 5000cGy/25 fractions of the reduced right maxillary tumor bed area, and
      • 6600cGy/33 fractions of the right maxillary tumor bed.
  • chemoimmunotherapy
    • 2022-11-24 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-10-28 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-10-03 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-09-01 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-08-05 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-07-07 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-05-03 ~ 2022-06-14 - cisplatin 40mg/m2 65mg 2hr (weekly x7, CCRT)

==========

2022-11-25

  • Despite the absence of tumor evidence by sinoscopy (2022-11-17), the nasopharynx MRI (2011-11-01) suggested a tissue proof to rule out recurrence for the abnormally enhancing lesions near the reconstruction area.
  • In addition to slight tachycardia (108 pulses per minute) and decreased SpO2 (94%), otherwise vital signs were unremarkable.
  • Except for slightly low serum potassium (3.3 mmol/L) and low HGB (11.3 g/dL), all lab results were generally normal on 2022-11-24.
  • The active prescription is working as intended.

2022-10-04

  • The available data now argues for adjuvant chemotherapy in mesenchymal chondrosarcoma, with little reliable data on craniofacial lesions in particular. The optimal drug combination to be employed has not been well-defined. (ref: Systemic treatment for primary malignant sarcomas arising in craniofacial bones. Front Oncol. 2022;12:966073. doi:10.3389/fonc.2022.966073)
  • In mesenchymal chondrosarcoma, treatment with Ewing sarcoma-like chemotherapy regimens may be considered, although data supporting its use is even more limited given its rarity. (ref: Systemic Therapy for Chondrosarcoma. Curr Treat Options Oncol. 2022;23(2):199-209. doi:10.1007/s11864-022-00951-7)
  • It was reported that ifosfamide-doxorubicin may be more beneficial in younger patients with >5 cm, high-grade, soft-tissue-sarcoma of the trunk or extremity in synovial-cell, dedifferentiated-liposarcoma, myxofibrosarcoma, round-cell-liposarcoma, undifferentiated-pleomorphic-sarcoma, and undifferentiated-sarcoma-not-otherwise-specified. (ref: The role of Ifosfamide-doxorubicin chemotherapy in histology-specific, high grade, locally advanced soft tissue sarcoma, a 14-year experience. Radiother Oncol. 2021;165:174-178. doi:10.1016/j.radonc.2021.10.019)
  • It was possible to treat soft tissue sarcoma using a regimen using a daily dose of mesna equivalent to that of ifosfamide. (ref: Crossover randomized comparison of intravenous versus intravenous/oral mesna in soft tissue sarcoma treated with high-dose ifosfamide. Clin Cancer Res. 2003;9(16 Pt 1):5829-5834.)
  • TPR, blood pressure, and SpO2 during the hospital stay, as well as lab data on 2022-09-29 were grossly stable or normal.

701346384

221124

{expired}

[exam findings]

  • 2022-11-22 Embolization (TAE) - abdomen
    • IMP: Active bleeding of ileocecal branch of SMA s/p TAE.
  • 2022-11-16 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric polyps, body
    • Suggestion:
      • No active bleeder nor coffee ground material was noted during this exam.
      • Biopsy of polyp was NOT done due to suspected GI bleed setting
  • 2022-11-15 CT - abdomen
    • Clinical history: 37 y/o male patient with bloody stool twice today. denied abodminal pain
    • Past Histories: brain tumor appendectomy 2 weeks ago.
    • With and without contrast enhancement CT of abdomen - whole:
      • Irregular fluid accumulation (9.7x4.1cm) in right lower abdomen with air bubble retention, could be due to abscess formation.
      • Generalized low density over liver parenchyma, suggesting fatty liver.
      • Right lower lung collapse.
    • Impression:
      • RLQ abscess.
      • Fatty liver.
      • Right lower lung collapse.
  • 2022-11-15 ECG
    • Sinus tachycardia with short PR
    • Possible Left atrial enlargement
    • Left axis deviation
  • 2022-11-08 SONO - abdomen
    • Imp: Mild fatty liver.
  • 2022-10-31 L-spine AP + Lat (including sacrum)
    • mild scoliosis of the L-spine
    • unremarkable change in the width of the bony spinal canal
    • compession fractures at L3, L2, L1,T12, T11 and T10 vertebral bodies
    • mild decreased disc spaces in the upper L-spine discs
  • 2022-10-18 CXR (erect)
    • Enlarged cardiac shadow. Consolidation patches at bilateral lower lung field. Bilateral pleural effusion.
  • 2022-10-18 CT - abdomen
    • Dilatatation of appendix. Fat stranding at RLQ with minimal air density. Focal small bowel ileus.
    • Partial consolidation at bil. lungs.
  • 2022-08-09 MRI - brain
    • Known a case of left parietal-occipital GBMs S/P operative removal. Still presence of several ill-defined mass lesions at the same areas. Marked progression of these heterogeneous enhancing tumors as compared with prior MRI (2022/05/10).
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2022-06-09 CXR
    • Linear band opacity over Rtmid lung zone, residual consolidation or atelectatic lung parenchyma
    • Fine recticular opacities at left midlung zone, residual inflammatory change or fibrotic change
  • 2022-05-10 MRI - brain
    • Known a case of left parietal-occipital GBMs S/P operative removal. Still presence of several ille-defined mass lesions at the same areas. Progression of these heterogeneous enhancing tumors as compared with prior MRI (2021/12/16).
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2022-04-27 CXR
    • Extensive consolidation and ground glass opacity with air-bronchograms over bilateral lungs mainly involing upper lobes, with small Lt pleural effusion
    • Reduced lung volume
  • 2022-04-22 CT - lung
    • Consolidation over right upper lobe and left upper lobe and less significantly at right lower lobe and left lower lobe is found. Air-bronchogram is found. Pneumonia is considered.
  • 2022-04-21 CXR
    • Consolidations in bilateral parahilar regions, suspected pneumonia, suggest clinical correlation and further study.
    • Mild blunting of costophrenic angle, left side, could be due to pleural effusion.
  • 2022-02-14, 2022-02-07, 2022-02-04 CXR
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and chest walls.
    • Blunted costophrenic angles due to effusion, pleural change, atelectatic lungs, etc.
  • 2022-02-01 CXR
    • Enlarged cardiac shadow. Increased haziness at left hemithorax. Bilateral clear costophrenic angles.
  • 2022-02-01 CT - brain
    • Brain tumors and edema at left parietal and temporal lobes, significantly increased in size and extent, causing brain swelling and brain herniation. Condition in progression.
  • 2022-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 18) / 66 = 72.73%
    • Conclutions
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Trivial TR
  • 2021-12-16 MRI - brain
    • malignant left T-Parietal brain tumor (wild type Glioblastoma), significantly increase in size and extent as compared with MRI on 2021/11/4, possibly involving the scalp region.
  • 2021-12-14 CT - brain
    • Findings
        1. multiple hypodense brain tumors with vasogenic edema at left parietal and temporal lobes, the tumor size and extent of edema has significantly increased and causing marked brain swelling and mass effect. Minimal intratumoral hemorrhage is present.
        1. brain herniation with midline shift to right side and downward transtentorial herniation.
        1. previous postoperative change with a burr hole at left frontal skull, and left temporal-parietal skull craniotomy.
    • Impression:
      • Brain tumors and edema at left parietal and temporal lobes, significantly increased in size and extent, causing brain swelling and brain herniation.
  • 2021-12-13 SONO - abdomen
    • Hepatic hemangioma, right lobe
  • 2021-11-29 CT - brain
    • Post-op at left frontoparietal skull.
    • Left temporoparietal malignancy with mass effect and progression.
    • Focal ICH in left parietal lobe.
  • 2021-11-08 Frozen section
    • Findings: multiple tumors in the left supratentorial brain.
    • Diagnosis: Tumor, brain, frozen section — Glioblastoma
  • 2021-11-08 Patho - brain/meninges (tumor)
    • Brain tumors, left supratentorial region, FS + craniotomy — Glioblastoma, IDH-wild type
    • Microscopically, the sections show a picture of glioblastoma of the brain tissue consisting of hypercellularity with striking pleomorphism, hemorrhage, pseudopalisading necrosis and endothelial proliferation of vessels.
    • Immunohistochemistry shows GFAP(+), IDH-1(-), P53 and Ki67: increased activity and EGFR(+) for tumor.
  • 2021-11-04 CT - brain for navigator
    • Finding: A low density mass, about 36 mm x 32 mm x 30 mm, with irregular peripheral enhacning rim and central necrotic chnage in left parietofrontal lobe, associating with extensive perifocal edmea and causing effacement of adjacent cortical sulci and mild midline shift to right side.
    • IMP: Left parietofrontal necrotic tumor. D/D: metastasis, abscess.
  • 2021-11-04 MRA - brain
    • Finding: multiple heterogeneous enhancing lesions in the left temporal lobe and left parietal lobe with the largest one, about 37mm, in the left parietal lobe. Moderate to severe perifocal edema was noted. Heterogeneous enhancement was noted.
    • IMP: multiple tumors in the left supratentorial brain.
  • 2021-11-04 CT - brain
    • Finding: a nodular lesion, about 39mm, in the left parietal lobe with moderate perifocal edema
    • IMP: a nodular lesion in the left parietal lobe.

[MedRec]

  • 2022-11-15 ~ 2022-11-24 POMR Metabolism and Endocrinology Zhang JiaHui
    • Discharge diagnosis
      • Peritoneal abscess, pus culture yields Enterococcus faecium and quinolone -resistant Escherichia coli.
      • Bacteremia
      • Sepsis with septic shcok
      • Acute respiratory failure s/p intubation on 2022/11/22
      • Low gastrointestinal bleeding with hypovolemic shock
      • Multiple organ failure with metabolic acidosis and disseminated intravascular coagulation
      • Malignant neoplasm of parietal lobe
    • CC
      • Bloody stool twice for one day.
    • Present illness
      • A 37-year-old patient has medical history of left supratentorial region Isocitrate dehydrogenase wild type Glioblastoma post left temporo-parieto-occipital craniotomy with remove brain tumor on November 5th last year, with seizure, then the image showed left frontoparietal skull and left temporoparietal malignancy with mass effect and progression and focal intracerebral hemorrhage in left parietal lobe were find after the operation. However, the brain lesion with brain tumors and edema at left parietal and temporal lobes, which significantly increased in size and extent, and causing brain swelling and brain herniation in last December. Depression and chronic hepatitis were also noted.
      • He received chemotherapy after the operation, then the chemotherapy was changed to targeted therapy from this August to October because of the brain cancer recurred in this August. The targeted therapy was stopped due to acute appendicitis in this October, he underwent the drainage of appendix with drainage device, percutaneous endoscopic approach on October 18 this year. He has no allergic to food or drugs, nor travel, occupation, contact or cluster recently.
      • He presented in the emergency room with the symptoms of bloody stool twice today, with nausea and weakness and dissy and hypotension, poor appetite and bilateral flank pain (left > right ) were also noted. In the emergency department, GCS was E4V5M6. No Murphy’s sign or McBurney’s point tenderness. A blood tests showed leukocytosis with bandemia 10.6%, anemia, elevated c-reactive protein and activated partial thromboplastin time. Blood gas showed respiratory alkalosis and metabolic alkalosis. Chest x ray showed patch density at right lower lobe. A computer tomography of the abdomen revealed right lower abdomen abscess, irregular fluid accumulation(9.7x4.1cm) with air bubble retention and right lower lung collapse. A Sono-and CT-guide drainage was arranged and a 8 Fr. pig-tail catheter was placed for drainage. Cefotaxime and Pantoloc were given. He is hospitalized on 2022/11/15.
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral Cefotaxime for empirical treatment of peritoneal abscess. Pig tail was indwelling. The pus discharge is submitted for pus culture. NPO except medications, PPI injection and electrolyte solution supplement due to suspect UGI bleeding. We also addition hemostatic agent and vitamin K1 for provided hemostatic. Panendoscopy was arranged, which report Reflux esophagitis LA Classification grade A. Superficial gastritis, Gastric polyps, body. Under excluded UGI bleeding, we give shift to oral PPI use, and try oral intake. Analgesic for pain control. Alk-p, serum calcium and albumin survey, excluded hypercalcemia.
      • Episode of fever up to 38.2 degree. Blood, uric acid and urine are submitted for blood culture, urinalysis and gout survey. Pyuria was excluded, but uric acid induce fever was considered, thus anti-gout agent was addition for anti-inflammation effected. Blood transfusion with LPRBC one unit for two days. Pus culture yields Enterococcus faecium and quinolone -resistant Escherichia coli. Antibiotic was change to Vancomycin and also was de-escalation of antibiotics Cefotaxime to cefuroxime. Intermittent high fever and pig tail without drainage amount, suspect pig tail. Contact radiology for pig tail revision, but radiology suggestion consulted general surgey for surgical drainage implacment. General surgey was conulted and phone contact VS 賴介文,suggest arrange non contrast or abdominal sonography for peritoneal abscess follow up.
      • Sudden of tachycardia, BP drop and abdominal pain. Normal saline and Dextran were hydration. Vasoconstriction pump use for maintain hemodynamic stable. Short of breath, exertional dyspnea and desaturation are noted. Inform family about patient critical condition and need intubation. Family agree intubation. Thus, he received intubation with fixed 24 cm with ventilator use. Tarry stool is noted, blood transfusion with LPRBC 2 unit. Antibiotic treatment with Vancomycin plus Cefepime for infection control. He will be transfered to MICU.
      • After transfer to ICU, ventialtor full supply and unstable of blood pressure combine massive amount bloody stool passage was found. NPO with adequate fluid for hydration and high dose PPI pump titration. Artery line and neck CVC were placement. Shock status, Albumin iv infusion and vasopressor agent with Levophed plus pitressin were titration. Ex-change antiboltic to IV Cravit, Cubicin, Doripenem plus IV Metronidazole were perscribed. Blood transfusion with LPRBC, FFP, Cryo and LRP were infusion for hypovolemic shock. Emergent contect contect radiology for TAE, impression of active bleeding of ileocecal branch of SMA s/p TAE. Correct imbalance of electrolyte. Well explain prognosis condition and highly mortalety rate to his family, they understood and refused any invade procedule, DNR was signed.
      • However, unstable of blood pressure under high dose vasopressor agent and poorly response with ventialtor high setting. The EKG reveal bradycardia then asystole, immeasurable pulsation and dilated pupil with inactive light reflex. The patient was prononcement expired at 12:29pm in 2022-11-24.

[consultation]

  • 2022-08-12 Radiation Oncology
    • Q
      • This 37-year-old man patient is a case of Left supratentorial region Isocitrate dehydrogenase wild type Glioblastoma post left temporo-parieto-occipital craniotomy with remove brain tumor on 2021/11/05.
      • This time, for headache from 2022/08/09. Brain MRI on 2022/08/09 showed 1. Known a case of left parietal-occipital GBMs S/P operative removal. Still presence of several ill-defined mass lesions at the same areas. Marked progression of these heterogeneous enhancing tumors as compared with prior MRI (2022/05/10). 2. MR angiography of the brain shows normal intracranial vessel including circle of willis.
      • Now, for evaluate whole brain radiotherapy. Thank you.
    • A
      • Palliative RT might help with limited symptoms relief. CT-simulation will be arranged on 20220815.
      • Plan to deliver 10~20 Gy/ 5~10 fx to the gross brain tumor. The exact dose schedule depends on the dose distribution with normal brain constraint considered after calculation.
      • RT will start around 20220817. Thank you very much.
  • 2022-04-25 Dermatology
    • Q
      • Under the impression of bilateral pneumonia, he was admitted to our ward for further management and treatment.
      • After admission, the patient has had right forearm herpes zoster since 2 months ago and treatment at INF OPD. Due to right forearm chronic erosion lesion, so we sincerly your help. TKS !!
    • A
      • This patient suffered from multiple group vesicles on R’t upper limb for months.
      • Imp: Post herptic neuralgia
      • Suggestion:
        • Arrange Ne-Na laser
        • mycomb *2 tubes/bid
  • 2022-02-02 Neurosurgery
    • Q
      • headache and progressive consciousness change in recent 2 days
      • no fever, no uri s/s, no dyspnea, no abdominal pain, no diarrhea, no tarry or bloody stool
      • 2021/12/16 Brain MRI: malignant left T-Parietal brain tumor (wild type Glioblastoma), significantly increase in size and extent as compared with MRI on 2021/11/4, possibly involving the scalp region.
      • 2021/12/14-2022/01/14 hospital stay, discharge diagnoses
        • Malignant neoplasm of parietal lobe
        • Left supratentorial region Isocitrate dehydrogenase wild type Glioblastoma post left temporo-parieto-occipital craniotomy with remove brain tumor on 2021/11/05
        • Headache
        • Nausea with vomiting, unspecified
        • Nontraumatic intracranial hemorrhage, unspecified
        • Abnormal results of liver function studies
        • Constipation, unspecified
      • Allergy: nil
      • Trauma hx: negative
    • A
      • A case of 36 y/o male; GBM s/p op/ CCRT;
      • Confuse status and headache noted;
      • F/U brain CT showed left PO residual/ relapse tumor with mass effect;
      • P: Control IICP/ IV hydration; further tumor excision?
  • 2022-01-12 Plastic and Reconstructive Surgery
    • Q
      • Owing to wound poor healing, we need your expertise for further management
    • A
      • assessment
        • scalp defect with bone and plate exposure, no pus, no infection sign now
        • patient is undergoing radiotherapy and chemotherapy now
      • plan and suggestion:
        • conservative treatment first, surgical intervention is not suitable for him due to C/T and R/T
        • caring wound with following method:
          • first day: prontosan bid (drip protosan gel into wound, then cover with white gauze) (about 600NT$)
          • 2nd day: duoderm gel bid (duoderm gel to fill the hole, then cover with white gauze) (about 300NT$)
          • 3rd day: Greenguard gel bid (greenguard fill the hole, then cover with white gauze) (about2000NT$)
          • then coming back to first day treatment method, 2nd day method, 3rd day method, and so on.
  • 2021-12-30 Gastroenterology
    • Q
      • The 36 y/o man has brain tumor /p op. No HBV and HCV, but his liver dysfunction without recovery, so we need your help for management. Thanks!
    • A
      • O
        • ALT 442 -> 181 -> 295
        • Bil(T) 0.44
        • rGT 254(20211209)
        • AlkP 85(20211209)
        • 20211213 abdominal echo: hemangioma
        • HbsAg(-)
        • Anti-HbsAb(+, low titer)
        • Anti-HbcAb(-)
        • Anti-HCV ab(-)
        • Anti-HAV ab IgM(-)
        • ceruloplasmin 0.128 g/L (Low)
      • A
        • abnormal liver function, cause?
      • P
        • Arrange cardiac sonography
        • Check ALP, rGT, TBI/DBI, PT, APTT, LDH to complete liver study
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
        • Stronger Neo Minophagen use (self-paid) 5 amp QD 3~5 days
        • Check alpha 1 antitrypsin (blood), 24hr urinary copper, blood copper
        • Consult ophthalmology for Kayser - Fleischer ring examination
        • Consider liver biopsy if his condition allows
  • 2021-12-16 Radiation Oncology
    • Q
      • Now, for evaluate whole brain ratiotherapy. Thank you.
    • A
      • CT-simulation will be arranged today. Due to the multiple tumors are still limited to Lt hemisphere, I’d consider partial instead of whole brain irradation for possible dose escalation.
      • Plan to deliver 60 Gy/ 30 fx to the gross brain tumors and the involved scalp region. RT will start around 20211220. Thank you very much.
  • 2021-11-30 Neurosurgery
    • Q
      • Headache, N/V since last night
      • No fever, no chills, no abdominal pain, no chest pain, no dyspnea, no focal weakness, no diarrhea, no discharge from OP wound
      • NKDA
      • PHx: Glioblastoma s/p left temporo-parieto-occipital craniotomy with remove brain tumor at parieto-occipital, Kocher EVD with ICP monitor 2021/11
    • A
      • a case of headache
      • P.H. malignant GBM s/p
      • conscious clear
      • no focal neurologic deficits
      • brain CT Post-op at left frontoparietal skull. Left temporoparietal malignancy with mass effect and progression. Focal ICH in left parietal lobe.
      • Plan:
        • consult oncologist for admission and CCRT
  • 2021-11-15 Hemato-Oncology
    • Q
      • Current problem: pathology showed Glioblastoma, IDH-wild type
      • We need your expertise for expertise for further management. Thanks a lot!
    • A
      • Accoring to NCCN guideline 2021, version2, CCRT (Temozolomide) is indicated for GBM.
      • Plan:
        • We will discuss with family and patient
        • We may take over this case if the sugical condition is stable for futher management.
  • 2021-11-15 Radiation Oncology
    • Q
      • Current problem: pathology showed Glioblastoma, IDH-wild type
      • We need your expertise for expertise for further management. Thanks a lot!
    • A
      • Adjuvant RT is indicated. CT-simulation will be arranged on 20211129.
      • Plan to deliver 60 Gy/ 30 fx to the preOP tumor bed and residual tumors. RT will start around 20211201 or 20211202. Thank you very much.
  • 2021-11-15 Rehabilitation
    • Q
      • His brain tumor pathologic showed Glioblastoma.
      • We need your help to do speech therapy and other rehabilitation program. Thank you very much.
    • A
      • A 36-year-old man presented with progressive headache, dizziness, nausea, vomiting and whole body weakness since last midnight. He denied any past systemic disease and surgical history was sinusitis status post operation about 10 years ago.
      • According to his and his family statement, he started to felt mild discomfort with headache and dizziness last night and the symptoms exacerbated in this early morning around 1 AM with severe headache, dizzness, nausea, and whole body weakness. Thus, he was sent to this emergency room very early in the morning. Laboratory studies showed no abnormal finding except mild hypokalemia. Brain CT revealed a nodular lesion about 39mm in the left parietal lobe, then MRI disclosed multiple tumors in the left supratentorial brain. Therefore, under the impression of left supratentorial brain tumor, he admitted for surgical intervention. we were consulted for further rehabilitation.
      • PE
        • 2021/11/15 05:30 T/P/R: 36.9 / 65bpm / 19bpm BP:108/67mmHg
        • height: 174.0 Body weight: 54.3 BMI:17.9
        • Consciousness: clear
        • Cognition: intact, oriented to time, person and place, could follow orders
        • Speech: no aphasia, no obvious dysarthria
        • Swallowing: take general diet without choking
        • Sphincter: urinary and stool continence
        • MP: RUE/RLE: 4/3, LUE/LLE: 4/3
        • Functional status: could perform bed mobility min A
        • BADL: needs mod assistance
        • MRS: 4 (needs follow-up)
      • Assessment
        • left parietal lobe glioblastoma post operation on 20211105
      • Plan
        • Rehabilitation programs: GYM first PT, OT rehabilitation programs
      • Goal: Ambulation with device CG
  • 2021-11-04 Neurosurgery
    • Q
      • Severe headache since today
      • First time of this symptoms
      • Nausea, vomiting, dizziness, weakenss
      • No fever, no URI symptoms, no chest pain, no abdominal pain, no trauma
      • Allergy: nil
    • A
      • a case of progressive headache
      • conscious clear
      • brain CT a nodular lesion, about 39mm, in the left parietal lobe with moderate perifocal edema
      • brain MRI multiple heterogeneous enhancing lesions in the left temporal lobe and left parietal lobe with the largest one, about 37mm, in the left parietal lobe. Moderate to severe perifocal edema. Heterogeneous enhancement.
      • Plan: risk benefit of brain surgery well explained to family and patient

[radiotherapy]

  • 2021-12-20 ~ 2022-01-28 completed RT to the Lt hemisphere: 46 Gy/ 23 fx. to the residual brain tumor: 60 Gy/ 30 fx

[chemoimmunotherapy]

  • 2022-10-12 - bevacizumab 10mg/kg 700mg 90min
  • 2022-09-28 - bevacizumab 10mg/kg 700mg 90min
  • 2022-09-12 - bevacizumab 10mg/kg 700mg 90min
  • 2022-07-21 ~ 2022-07-26 - temozolomide 320mg QDAC 5 days
  • 2022-06-23 ~ 2022-06-28 - temozolomide 320mg QDAC 5 days
  • 2022-05-19 ~ 2022-05-24 - temozolomide 320mg QDAC 5 days
  • 2022-04-19 ~ 2022-04-24 - temozolomide 320mg QDAC 5 days
  • 2022-03-22 ~ 2022-03-27 - temozolomide 320mg QDAC 5 days
  • 2022-02-24 ~ 2022-03-10 - temozolomide 120mg QDAC 14 days
  • 2022-01-20 ~ 2022-02-10 - temozolomide 120mg QDAC 21 days

==========

2022-10-12

  • Following standard brain RT and TMZ for multiple glioblastomas, the NCCN evidence blocks (2022-09-29 version 2.2002) recommends clinical trials, surgery for symptoms of large lesion, alternating electric field therapy, and palliative/best supportive care.

  • It has been reported in a review article that studies have been conducted using intra-arterial delivery of chemotherapeutics for the treatment of GBM, which may be considered as an optional last resort. (ref: A systematic review on intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme: The state-of-the-art. Front Oncol. 2022;12:950167. Published 2022 Sep 23. doi:10.3389/fonc.2022.950167 )

  • In addition, there is also an article reported CAR T cell therapy and its potential to be integrated into the therapeutic paradigm for aggressive gliomas in the future. (ref: Clinical utility of CAR T cell therapy in brain tumors: Lessons learned from the past, current evidence and the future stakes [published online ahead of print, 2022 Oct 3]. Int Rev Immunol. 2022;1-19. doi:10.1080/08830185.2022.2125963 )

700361559

221123

  • diagnosis - 2022-11-05 discharge note
    • Malignant neoplasm of biliary tract, unspecified
    • Malignant neoplasm of biliary tract, unspecified, sarcomatoid carcinoma with biliary differentiation, CK(+), CK7(+), CK20(-), p63(-) and Hepatocyte(-) with LN metastases and tumor seeding ( carcinomatosis), stage IV
    • Adeocarcinoma of the gallbladder with liver metastasis, lymph nodes metastases, and tumor seeding (carcinomatosis),cT4 N2 M1, Stage:IVB
    • Urinary tract infection, site not specified
    • Hypoalbuminemia
  • history - 2022-11-05 discharge note
    • HTN with medicine control for 20+ years
    • CAD with medicine control for 20+ years
    • BPH
    • Unclear liver disease, tumor or inflammation, since Aug 2021, initial admission at ShuangHo Hospital that UTI also told.
    • Liver abscess drainage was performed at ward on 2022/05/22
    • COVID-19 infection on 2022/05/28
  • exam findings
    • 2022-11-20, … CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
    • 2022-11-11 ECG
      • Normal sinus rhythm
      • Low voltage QRS
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-11-11 KUB
      • Degenerative joint disease of lumbar spine with marginal osteophytes.
      • Surgical clips retention over epigastric region.
      • Ileus with gas-filled distended bowel loops of the abdomen.
    • 2022-10-31 Abdomen
      • Spondylosis of the L-spine is noted.
      • Ascites is highly suspected.
    • 2022-10-18 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Sarcomatoid carcinoma with biliary differentiation
      • The specimen submitted consists of three strips of yellow gray soft tissue, labeled liver, measuring up to 0.6 x 0.1 x 0.1 cm. All for section.
      • The sections show a picture of sheets of poorly differentiated, polygonal and spindle-shaped neoplasic cells, arranged in short fascicles. Neither glandular nor squamous differentiation can be found.
      • IHC shows: CK(+), CK7(+), CK20(-), p63(-) and Hepatocyte(-). The finding is consistent with sarcimatoid carcinoma with biliary differentiation. Suggest clinic correlation.
    • 2022-10-17 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, elbows, S-I joints, hips, and knees.
    • 2022-07-22 CT - abdomen
      • History: liver abscess
        • 20220517 CT:Multicystic lesion in Rt lobe liver 10cm suspected abscess
        • A tumor 1.7cm in S6 with rim enhancement, suspected cholangiocarcinoma 20220519 S/P drainage was performed.
      • Indication: S5 tumor in progress.
      • Findings:
        • There is a heterogeneous lobulated soft tissue mass in the medial subhepatic space, directly attached the gallbladder, measuring 4.8 cm in size at the largest dimension.
          • Gallbladder cancer is highly suspected.
        • There is an ill-defined hypodense mass lesion measuring 3 cm in S5 of the liver. During dynamic study, this mass shows poor contrast enhancement in arterial phase and portal venous phase images, and mild centropedal enhancement in delayed phase images
          • Metastasis is highly suspected.
          • The differential diagnosis include Cholangiocarcinoma.
        • There are several enlarged nodes in the hepatoduodenal ligament that are c/w metastatic nodes.
          • In addition, There are lobulated soft tissue lesions in the periportal area of the liver hilum and ligamentum teres. Metastatic nodes are highly suspected.
        • There are several soft tissue nodules in RUQ omentum that are c/w tumor seeding.
          • In addition, There are few enhancing soft tissue lesions in bilateral lower pelvis that may be tumor seeding?
        • Prior CT identified multicystic lesions in right hepatic lobe is noted again, marked decreasing in size that is c/w liver abscess S/P catheter drainage and antibiotics treatment with near complete response.
        • Non-visualization of the spleen is noted. please correlate with clinical condition.
        • Several gallstones are noted.
        • Others
          • There is no focal abnormality in the biliary system, pancreas, & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Adeocarcinoma of the gallbladder with liver metastasis, lymph nodes metastases, and tumor seeding (carcinomatosis) is highly suspected.
          • According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for gallbladder cancer: T4 N2 M1, Stage:IVB
        • A poor enhancing mass 3 cm in S5 liver is noted.
        • Metastasis is highly suspected.
        • The differential diagnosis include Cholangiocarcinoma.
  • chemoimmunotherapy
    • 2022-11-02 - irinotecan liposome 70mg/m2 125mg 1.5hr + leucovorin 400mg/m2 700mg 1hr + fluorouracil 2400mg/m2 4000mg 46hr

[assessment]

  • Fatal neutropenic sepsis occurred in 0.8% of patients receiving irinotecan (liposomal). Severe or life-threatening neutropenic fever or sepsis occurred in 3% and severe or life-threatening neutropenia occurred in 20% of patients receiving irinotecan (liposomal) in combination with fluorouracil and leucovorin.
  • When irinotecan is suspected of causing acute gastroenteritis, UGT1A1 genotyping might be utilized to confirm the homozygous state (homozygous UGT1A1*28).
  • Atropine 0.5mg SC is recommended as a premedication prior to the use of irinotecan in the next chemotherapy if there is no contraindication.

700384079

221122

  • exam findings
    • 2022-11-16, -09-28, -08-29, -08-25 CXR
      • Atherosclerotic change of aortic arch
    • 2022-11-16 CT - abdomen
      • History: UGI bleeding
        • 20220808 gastroscopy: One 25mm ulcer with elevated margin was noted at AW side of bulb/SDA. Patho: duodenal adenocarcinoma
        • 20220817 CT: duodenal adenocarcinoma or metastatic node with superior mesenteric vein invasion? cT4N2M0, cstage: IIIB
      • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings: Comparison: prior CT dated 2022/08/17.
        • Prior CT identified lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness is noted again, increasing in size to 2.1 cm. The stomach shows marked distension that may be gastric outlet obstruction?
          • Please correlate with gastroscopy.
          • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein is noted again, decreasing in size to 1.8 cm that may be metastatic node S/P C/T with partial response .
          • The differential diagnosis include adenocarcinoma with exophytic growth?
          • Prior CT identified two enlarged nodes in the hepatoduodenal ligament are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response.
        • There are several gallstones.
        • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
        • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
        • There is no focal abnormality in the liver, biliary system, pancreas, spleen & both kidney.
        • There is no ascites.
        • There is no bowel obstruction.
        • The IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Adenocarcinoma of the duodenal bulb shows mild increasing in size. However, metastatic nodes show decreasing in size.
    • 2022-08-23 All-RAS + BRAF mutations assay
      • All-RAS mutations assay
        • Detection range
          • KRAS codon 12, 13, 59, 61, 117, 146
          • NRAS codon 12, 13, 59, 61, 117, 146
        • Results
          • There was no variant detected in the KRAS/NRAS gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
      • BRAF mutations assay
        • Detection range
          • BRAF codon 600
        • Results
          • There was no variant detected in the BRAF gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • 2022-08-23 CT - chest
      • Pancreatic cancer with suspect duodenal bulb and SMV invasion
      • MDCT (256-detector rows, GE Revolution, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Findings
        • Lungs: minimal centrilobular nodules at posterobasal segment of RLL.normal appearance of RUL, RML, and left lung.
        • Mediastinum and hila: no enlarged LN or mass.
          • the trachea and main bronchi are normallly identified without endobronchial lesion.
        • Vessels:
          • moderate calcified plaques of the LAD coronary artery.
          • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta/aortic root.
          • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: unremarkable.
        • Chest wall and visible lower neck: unremarkable.
        • Visible abdominal contents: Pancreatic head cancer with suspect duodenal bulb and SMV invasion
          • multiple small gall bladder stones
        • Visualized bones: multiple marginal spurs of vertebrae..
      • Impression:
        • minimal bronchiolitis in RLL-S10. moderate LAD CAD.
    • 2022-08-17 CT - abdomen
      • History: UGI bleeding
        • 20220808 gastroscopy: One 25mm ulcer with elevated margin was noted at AW side of bulb/SDA. Patho: duodenal adenocarcinoma
      • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness.
          • Adenocarcinoma of the duodenal bulb is highly suspected.
          • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein that may be metastatic node.
          • The differential diagnosis include adenocarcinoma with exophytic growth?
          • There are two enlarged nodes in the hepatoduodenal ligament that may be metastatic nodes.
        • There are several gallstones.
        • There are few metalic coils implantation at the gastroduodenal artery that are c/w TAE for prior GI bleeding.
        • Abdominal aorta shows atherosclerosis and mild intramural thrombus formation.
        • There is no focal abnormality in the liver, biliary system, pancreas, spleen & both kidney.
          • There is no ascites.
          • There is no bowel obstruction.
          • The IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Adenocarcinoma of the duodenal bulb is highly suspected.
    • 2022-08-10 Embolization (TAE: trans arterial embolisation) - abdomen
      • TAE of duodenal hemorrhage via right common femoral artery puncture using Seldinger technique revealed:
        • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
        • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
        • Active bleeding of gastroduodenal artery.
        • We used microcatheter for superselective catheterization due to easy spasm, tortuous, small size of bleeding artery.
        • TAE was performed using four microcoils (2-4-42mm x3 and 2-6-85mm x1) plus some gelfoam pieces.
        • No procedure-related complication during the whole procedure. Remain the arterial sheath (4 Fr) at right inguinal region. Thanks for your further care.
      • IMP: Active bleeding of gastroduodenal artery s/p TAE.
    • 2022-08-09 Patho - duodenum biopsy (malignancy)
      • Duodenum, AW side of bulb/SDA, biopsy — moderately differentiated adenocarcinoma
      • Microscopically, it shows moderately differentiated adenocarcinoma composed of proliferation of irregular neoplastic glands with stromal invasion. The tumor shows nuclear hyperchromasia, pleomorphsim, prominent nucleoli and increased N/C ratio.
      • Immunohistochemical stain — CK(+), CDX-2(+)
    • 2022-08-08 Panendoscopy
      • Diagnosis
        • Severe duodenal ulcer, Forrest classification type Ib, suspected tumor, s/p hemostasis with APC and biopsy
        • Incomplete of stomach
      • Suggestion
        • NPO and PPI pump for 3 days.
        • Due to anticipated prolonged NPO time, suggest TPN supply
          • Calories: 25kcal per ideal body weight
          • Protein: 1.5gm per ideal body weight
        • Consult interventional radiologist and surgical department if further bleeding.
        • Weaning ventilator ASAP
    • 2022-08-04 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (74.7 - 17.0) / 74.7 = 77.24%
        • M-mode (Teichholz) = 77
      • Conclusion:
        • Normal chamber size
        • Septal hypertrophy
        • Adequate LV and RV systolic function
        • Mild MR and PR
        • No regional wall motion abnormalities
    • 2022-08-01 Panendoscopy
      • Diagnosis
        • Superfical gastritis, antrum
        • Duodenal ulcer, junction of 1st and 2nd portion, LC side, Forrest classification IIb
      • Suggestion
        • NPO and give high dose PPI
    • 2022-07-29 ECG
      • Sinus tachycardia
      • Right bundle branch block
      • Abnormal ECG
    • 2022-04-19 SONO - abdomen
      • Fatty liver, mild to moderate
      • GB stone, multiple
    • 2021-01-27 ECG
      • Sinus tachycardia
      • Right bundle branch block
    • 2019-11-04 CPA, carotid phonoangiograph
      • Sonographic diagnosis:
        • Moderate atheromatous lesions in bil BIF and right proximal ICA.
        • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows; stenotic flow in left MCA, more severe over proximal segment; resistant flow in right CCA and left ECA, suspect distal stenosis, suggest clinical correlation and further evaluation.
        • Poor temporal windows for left PCA and right ACA.
        • Normal left ophthalmic arterial flows; reverse flow in right OA.
        • Suggest MRA (neck + intracranial arteries) for further study if no contraindication.
    • 2018-03-26 SONO - hepatobiliary
      • Fatty liver.
      • GB stone.
    • 2018-02-18 ECG
      • Sinus tachycardia
      • Right bundle branch block
    • 2017-07-04 Barium Enema (double contrast)
      • Double contrast study of LGI series revealed:
        • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
        • Redundancy of T-colon.
        • Much stool retention in colon.
        • Normal contour and mucosal pattern of the colon.
        • Normal haustration and peristalsis of the colon.
  • consultation
    • 2022-08-24 Hemato-Oncology
      • Q
        • For neoadjuvant chemotherapy of pancreatic cancer suspected duodenal invasion suspected SMV invasion
        • THis is a 56 y/o male with history of DM, hypertension under medication control
        • He was admitted since 20220730 due to gastric ulcer with bleeding complicated with hypovolemic shock s/p ETT intubation (extubated), EGD hemostasis and active bleeding of gastroduodenal artery s/p TAE on 20220810. There was an incidental finding of duodenal neoplasm, pathology revealed adenocarcinoma. CT revealed adenocarcinoma of the duodenal bulb, suspect SMV invasion.
        • Further tumor biomarker study revealed CA-199 = 1089; while other biomarkers were within normal range, pancreatic cancer suspected duodenal bulb invasion was suspected.
        • Due to above, surgical intervention was not recommended in the first place, suggested by GS Dr. Wu.
        • We sincerely need your expertise for chemotherapy evaluation and management.
      • A
        • O
          • Abdominal CT show:
            • There is lobulated wall thickening in duodenal bulb measuring 1.5 cm in wall thickness.
            • Adenocarcinoma of the duodenal bulb is highly suspected.
            • In addition, There is a poor enhancing mass measuring 2.5 cm in the medial aspect of the duodenal 2nd portion with direct invasion the superior mesenteric vein that may be metastatic node. The differential diagnosis include adenocarcinoma with exophytic growth?
            • There are two enlarged nodes in the hepatoduodenal ligament that may be metastatic nodes.
          • Pathology: Duodenum, AW side of bulb/SDA, biopsy — moderately differentiated adenocarcinoma.
            • Immunohistochemical stain — CK(+), CDX-2(+)
        • Impression:
          • Duodenum adenocarcinoma with SMV invastion, T4N2Mx, stage IIIB at least
        • Suggestion:
          • Arrange chest CT, EUS for complete staging
          • For Locally unresectable duodenum cancer, systemic chemotherapy is indicated (goal for down stage)
          • Arrange port A insertion if patient agree further chemotherapy and check HbsAg, Anti Hbc, Anti HCV
          • Thanks for your consultation. If there is any problem, please feel free to let us known.
    • 2022-08-18 General and Gastrointestinal Surgery
      • Q
        • For duodenal adenocarcinoma
        • This is a 56 y/o male with history of DM, hypertension under medication control
        • He was admitted since 07/30 due to gastric ulcer with bleeding complicated with hypovolemic shock s/p ETT intubation (extubated), EGD hemostasis and active bleeding of gastroduodenal artery s/p TAE on 08/10. There was an incidental finding of duodenal neoplasm, pathology revealed adenocarcinoma. CT revealed adenocarcinoma of the duodenal bulb, suspect SMV invasion.
        • We sincerely need your expertise for surgical intervention evaluation and management.
      • A
        • A case suspect of duodenal or pancreatic tumor
        • further op will arrange on 8/24
        • we will take over for this case on 8/22
        • Due to pancreatic neck ca with SMV invasion and tumor seeding is impression
        • Suggest further neoadjuvant chemotherapy first for tumor down stage
    • 2022-08-11 Diagnostic Radiology
      • Q
        • For TAE (trans arterial embolisation)
        • The 57-year-old male patient, he has history of: 1. Type 2 diabetes mellitus for years. 2. Hypertension for years. He was under regular medical treatment in our GI and Family Medicine Department OPD in the recent years. He is a bus driver who fainted once in the toilet during his lunch break yesterday. This time, he complained of black stool for about a week. And also has dizziness again and cold sweat after going to the toilet last night.
        • At ER, his consciousness was clear. KUB showed: Increase bowel gas and presence of ileus.The serum examination showed : glucose: 336 mg/dL; BUN: 62 mg/dL; Creatinine: 1.83 mg/dL; WBC: 11.10 *10^3/uL; HGB: 8.8 g/dL. Under the impression of upper gastrointestinal bleeding, IV Panzolec pump were given and he was admitted for further evaluation and management. After admitted to ward, the EGD performed on 08/01 showed gastric ulcer Forrest class IIb. His tarry stool passage mildly subsided since then(no loosen nor sticky unshaped stool, hemoglobin level around 8.0-8.7) s/p PPI high dose pump and then Q12H since 08/05.
        • However, on 08/06, he was noted dizziness, bloody stool passage, the discharge was postponed. Following Hb today revealed 6.4, EGD was arranged this afternoon. Hematemesis with consciousness disturbance developed when undergo anesthesia surveillance, with cold and wet skin, tachycardia, pale appearance, suspect hypovolemic shock. ETT intubation was performed to secure airway(Dormicum x1, Esmeron x1), foley catheter and CVC were also inserted in the same time. Fluid resuscitated with N/S 500 cc and LPRBC 2U ST, vesopressor with levophed 2 amps in 500 N/S run 20 cc/hr, PPI pump with 5 amps in 500 N/S run 20 cc/hr. His family was informed and fully understood current situation. After emergent management, the patient’s condition was temporarily under control and was transferred to MICU for further evaluation and management on 2022-08-08.
        • After transferred to MICU, on ventilator full support and blood transfusion with LPRBC 4u, FFP 4u and cyro 10u stat. On vasopressor with levophed titration(8/8-) and N/S 500ml challenge for unstable hemodynamic condition. Arranged pandoscope immediately which report showed Severe duodenal ulcer, Forrest classification type Ib, suspected tumor, s/p hemostasis with APC and biopsy. Jusomin 5amp iv stat for metabolic acidosis. Extubation on 8/9 and then on nasal cannula support. However, fresh bloody around 200ml via NG tube was noted now, so we contact GI who suggested If active bleeding, arrange TAE. Therefore, we need your help for TAE examination. Thanks!!
      • A
        • According to the clinical condition and imaging findings, TAE is indicated.
  • chemoimmunotherapy
    • 2022-11-08 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
    • 2022-10-25 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
    • 2022-09-28 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
    • 2022-09-13 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
    • 2022-08-29 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr

[note]

  • GOLF regimen ref:
  • Simplified/Same Day(s)-GOLF as First-line Treatment of Metastatic Carcinoma of Unknown Primary (CUP), Suggestive of Pancreatobiliary Tumors. JOP. 2019;20(5):121-124;
  • Biweekly triple combination chemotherapy with gemcitabine, oxaliplatin, levofolinic acid and 5-fluorouracil (GOLF) is a safe and active treatment for patients with inoperable pancreatic cancer. J Chemother. 2008;20(1):119-125. doi:10.1179/joc.2008.20.1.119;
  • A novel biweekly multidrug regimen of gemcitabine, oxaliplatin, 5-fluorouracil (5-FU), and folinic acid (FA) in pretreated patients with advanced colorectal carcinoma. Br J Cancer. 2004;90(9):1710-1714. doi:10.1038/sj.bjc.6601783

[assessment]

  • The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.

  • The decreased CA199 marker also served as a side evidence that the regimen is still effective.

    • 2022-11-21 CA199 346.54 U/mL
    • 2022-10-11 CA199 740.79 U/mL
    • 2022-09-13 CA199 1286.58 U/mL
  • Data available indicate stable vital signs, and there is no problem with the active prescription.

700568782

221122

  • diagnosis - 2022-11-10 discharge note
    • Right breast invasive carcinoma with liver and bone metastasis, cT4N1M1, stage IV. ECOG:0
    • Viral hepatitis B without hepatic coma
    • Upper Gastrointestinal Bleeding, vomit OB: 3+
    • Reflux esophagitis, lower esophagus, LA classification, grade B
    • Gastric ulcer
    • Superfical gastritis
  • exam findings
    • 2022-11-21 CXR
      • Ground glass opacity in RLL.
    • 2022-11-10 Patho - stomach biopsy
      • Stomach, AW of antrum, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
    • 2022-11-10 Panendoscopy
      • Reflux esophagitis, lower esophagus, LA classification, grade B
      • Superfical gastritis, antrum
      • Gastric ulcer, antrum, AW, s/p biopsy
    • 2022-11-08 CT - abdomen
      • Clinical history: 54 y/o female patient with breast cancer with liver mets, elevated TBI and liver dysfunction.
      • Findings
        • Diffuse liver tumors in both lobes of the liver, suggesting liver metastasis. Progression as compare with CT study on 20220505.
        • Presence of gallbladder stones.
        • Unremarkable change of the spleen, pancreas and both kidneys.
        • No enlarged lymph node in the paraaortic region.
        • Presence of ascites.
        • Bilateral pleural effusion with right lower lung collapse.
        • Diffuese osteoblastic and osteolytic lesions in the bones, could be due to bone metastasis.
      • Impression:
        • Liver metastasis and ascites with progression.
        • Diffuse bone metastasis.
        • Bilateral pleural effusion with right lung collapse.
        • GB stones.
    • 2022-11-07 ECG
      • Normal sinus rhythm
      • ST & T wave abnormality, consider anterior ischemia
      • Prolonged QT
      • Abnormal ECG
    • 2022-11-05 KUB
      • Diffuse bony metastases of the lower T-spine, L-spine, sacrum, and bilateral ilium.
    • 2022-11-05 CXR
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Osteoblastic bony metastases in the lower T-spine and L-spine are noted after correlate with prior CT.
    • 2022-10-28 Whole body PET scan
      • Findings
        • There was increased FDG uptake in the some mediastinal lymph nodes and in multiple focal areas in the liver.
        • There was increased FDG uptake in multipe bones including the skull, mandible, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, bilateral clavicle, bilateral scapulae, sacrum, bilateral pelvic bones, bilateral humeri and femurs.
      • Impression
        • Glucose hypermetabolism in multiple focal areas in the liver and in multipe bones as mentioned above, suggesting multiple liver and bone metastases.
        • Glucose hypermetabolism in some mediastinal lymph nodes. Metastatic lymph nodes should be considered.
    • 2022-10-28 ENT Hearing Test
      • Tymp:
        • Bil type A.
      • ART:
        • R’t contra absent.
        • L’t WNL.
      • E-tube function test:
        • Bil poor.
      • PTA
        • Reliability FAIR
        • Average RE 18 dB HL; LE 19 dB HL.
        • Bil WNL.
    • 2022-10-27 Sonography of hepatobiliary system
      • Findings
        • Bil. liver tumors (up to 6.39cm).
        • Moderate amount ascites.
        • Gallbladder stones (0.65cm, 1.10cm).
        • Patency of PV, HVs, IVC and aorta in hepatic portion.
        • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/bowel gas.
        • Normal appearance of spleen.
        • No evidence of pleural effusion.
        • Normal appearance of kidneys.
      • IMP:
        • Bil. liver tumors (up to 6.39cm). Moderate amount ascites. Gallbladder stones (0.65cm, 1.10cm).
    • 2022-10-27 CXR
      • Consolidation at RLL.
    • 2022-05-09 Tc-99m MDP whole body bone scan
      • Highly suspected multiple bone metastases in multiple T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral S-I joints, left ischium, bilateral humeri, and femurs.
      • Increased tracer uptake in the skull and hips, the nature is to be determined, suggesting follow-up with bone scan in 3 months for investigation.
    • 2022-05-05 CT - abdomen
      • Findings
        • S/P right breast operation.
        • Bil. liver metastases (up to 6.5cm). AP shunt at right hepatic lobe. Bil. liver cysts (up to 2.6cm).
        • Multiple bony metastases.
        • Normal appearance of spleen, pancreas, adrenals and kidneys.
        • Tiny gallbladder stones (2-3mm).
        • Patency of portal vein.
        • No ascites, nor enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • No abnormal density at bilateral basal lungs.
      • IMP:
        • S/P right breast operation.
        • Multiple liver and bony metastases.
    • 2022-03-18 SONO - abdomen
      • Metastasis 9 cm in S4 liver is highly suspected.
        • Please correlate with contrast enhanced dynamic CT.
        • Several hepatic cysts on both lobes.
      • Two polyp-like lesion 1.29 cm and 0.86 cm in the gallbladder are suspected.
    • 2022-01-18 Patho - breast biopsy (no need margin)
      • PATHOLOGIC DIAGNOSIS
        • Breast, right, partial mastectomy — Invasive carcinoma of no special type, s/p CDK 4/6 inh + AI treatment
        • Resection margin: involved
        • Lymph node, right left axilla/ sentinel, lymphadenecomy — Not received
        • AJCC 8 th edition, Pathology stage: Anatomic stage: ypStage IV, ypT2Nx (if cM1)
      • MACROSCOPIC EXAMINATION
        • Breast: Size: 4.5 x 3.1 x 3.0 cm
        • Skin: Size: 4.1 x 1.3 cm.
        • Nipple: Not Included
        • Tumor: Size: 2.8 x 2.0 x 1.7 cm.
        • Resection Margin: involved
        • Lymph node: Not received
        • Representative sections are taken and labeled as: A1-6.
      • MICROSCOPIC EXAMINATION
        • FOR INVASIVE CARCINOMA
          • Histologic type: Invasive carcinoma of no special type
          • Size of invasive carcinoma: 2.8 x 2.0 x 1.7 cm.
          • Histologic grade (Nottingham histologic score): grade II (score 7)
            • Tubule formation: score 3
            • Nuclear pleomorphism: score 3
            • Mitotic count: score 1
          • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent; The immunohistochemical stain of CK7 is negative.
          • Chest wall invasion deeper than pectoralis muscle: not received
        • FOR DUCTAL CARCINOMA IN SITU
          • Tumor size (cm): several foci, measuring up to 0.5 x 0.25 cm, intermix with invasive carcinoma.
          • Nuclear grade: 3
          • Architectural pattern: Non-comedo (solid and cribriform)
          • Tumor necrosis: Present
        • Margins: Involved ( unspecified margin)
        • Nodal status: Not received
          • number of lymph node examined: Not received
          • number with macrometastases (>2mm): Not received
          • number with micrometastases (>0.2~2mm and/or >200 cells): Not received
          • number with isolated tumor cells (<=0.2mm and <=200 cells): Not received
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
          • In the Breast: Probable or definite response to presurgical therapy in the invasive carcinoma
          • In the Lymph nodes: No lymph nodes removed
        • Lymphovascular invasion: present
        • Perineural invasion: present
      • IMMUNOHISTOCHEMICAL STUDY
        • ER (Ab): Positive (strong, 80 %)
        • PR (Ab): DCIS: Positive (strong, 10%); IDC: Negative
        • HER-2/Neu (Ab): DCIS: Positive (3+); IDC: Equivocal (2+)
          • The HER2/NEU In-Situ Hybridization Test from Taipei Institute of Pathology is NEGATIVE.
          • There is NO amplification of HER2 detected.
        • Ki-67: < 5%
    • 2022-01-17 ECG
      • Normal sinus rhythm
      • Possible Left atrial enlargement
      • Nonspecific ST abnormality
    • 2021-12-31 SONO - abdomen
      • Diagnosis
        • Fatty liver,mild
        • Suspected liver cyst,left
        • Liver tumors,bil.Propable metastases
        • Suspected GB polyp
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • consultation
    • 2022-11-09 Family Medicine
      • Q
        • This time, she has nasuea and vomit and poor intake, so she was admission for supprtiva care ( IVF & Bfluid ) on 11/5 22. Howevee, the patient’s condition, liver function worse, and request the combine hospice care, so we need your help, thanks a lot!!
      • A
        • 54-year-old female, right breast cancer with liver and bone metastasis
        • Consciousness clear, ECOG 2
        • We will arrange hospice combine care and follow her condition

[assessment]

  • There was an increase in serum bilirubin (both direct and total), AST, ALT, and ammonia as a result of poor liver function.
  • Presently, Baraclude (entecavir), Baogan (silymarin) and Lactul Syrup (lactulose) are used to treat liver insufficiency symptoms.
  • Hospice combined care has been arranged.
  • Her edema in the lower extremities might be mitigated by the use of albumin (2.8 g/dL 2022-11-05).

700361615

221121

{drug identification}

requesting drug identification for 4 items.

the 3 items are identified as following while the other 1 item remains unknown.

  • Broen (l-cysteine 20mg, bromelain 20000unit)
  • Acetal (acetaminophen 500mg)
  • Sodicon (dextromethorphan 15mg)

The drug will be sent back to ward by the in-hospital porter.

700952001

221121

  • diagnosis 20221001 discharge
    • Infiltrating duct carcinoma of left breast, pT2N0M0 post MRM (20131017), ER:positive (90%), PR:40%, Her2/neu:equivocal(2+, FISH negative), P53(-), Ki-67 index 30%, bone metastases
    • Essential (primary) hypertension
  • exam findings
    • 2022-11-18 KUB
      • Fecal material store in the colon.
      • Spondylosis of the L-spine is noted.
      • S/P total hip arthroplasty, left hip and the screw penetration into the pelvis.
    • 2022-11-18 CXR
      • Spondylosis of the T-spine
      • Few nodular opacity projecting in the left upper and middle lung are suspected. Please correlate with CT.
      • S/P partial Mastectomy, left.
    • 2022-10-25 L-spine AP + Lat (including sacrum)
      • Straightening alignment of lumbar spine. Degenerative change of the spine with marginal spur formation. Status post left total hip replacement.
      • Multiple geographic areas of sclerotic bone change in visible bones with pedicle involvement, compatible with bone metastases.
    • 2022-10-25 Pelvis + Lt. Hip Lat
      • Status post left total hip replacement. Mild osteoarthritis change of right hip joint with joint space narrowing (more at superior aspect), subchondral sclerosis and marginal spur formation.
    • 2022-10-25 CXR
      • Ill-defined faint patch at LUL.
      • Degenerative change of the spine with marginal spur formation.
    • 2022-10-25 CT - brain
      • Brain atrophy.
    • 2022-10-25 ECG
      • Sinus tachycardia
      • Left axis deviation
    • 2022-09-17 MRI - brain
      • Bony metastases at skull, clivus and C2 vertebral body.
      • Suspected metastases at pituitary stalk and gland.
    • 2022-09-16 CT - chest
      • Left breast cancer s/p MRM with bilateral lung meta, liver meta and mediastinal lymphadenopathy, in progression.
      • Bone meta. Please correlate with bone scan study.
    • 2022-06-17 CT - chest
      • S/P mastectomy at left side.
      • Bilateral lung meta and mediastinal lymphadenopathy
      • Liver meta
      • Bone meta.
    • 2022-04-28 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20210702, more new bone lesions are noted, suggesting multiple bone metastases in progression.
    • 2022-02-05 CT - abdomen
      • S/P mastectomy at left side
      • Suspected bone meta at L1
      • S/p Total hip replacement over left side is found. The nails of the S/p Total hip extends to pelvic cavity.
    • 2021-07-02 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20200210, the lesions in the left 10th costovertebral junction, L1 spine and sarum are new. Bone metastases should be considered frist.
      • The lesion in the L5 spine is a little more evident. Either degenerative spine disease in a little more severe status or bone metastasis may show this picture. Please correlate with other clinical findings for further evaluation.
      • Suspected benign lesions in the maxilla, L2 spine, right sternoclavicular junction, bilateral shoulders, S-I joints and knees.
    • 2021-05-14 SONO - abdomen
      • Fatty liver, mild to moderate
      • Suspected fatty infiltration of pancreas
    • 2020-02-10 Tc-99m MDP whole body bone scan
      • A hot spot at the left femoral head and neck, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in the maxilla, L2-5 spines, right sternoclavicular junction, bilateral shoulders, S-I joints, and knees.
    • 2020-02-07 Pelvis & Lt. Hip Lat
      • Osteoporotic change at the left femoral head is noted.
      • Chip fracture or Marginal osteophyte formation at the lateral aspect of left acetabulum is noted. please correlate with clinical condition or CT.
    • 2018-03-09 Bone densitometry - spine
      • AP L-spines, BMD of L1-4 0.763 gms/cm2, about 2.1 SD below the peak bone mass (76%) and 0.1 SD above the mean of age-matched women (102%).
      • IMP: Osteopenia.
    • 2018-03-09 Bone densitometry - hip
      • Left hip, BMD is 0.530 gms/cm2, about 2.6 SD below the peak bone mass (66%) and 0.7 SD below the mean of age-matched people (90%).
      • IMP: Osteoporosis
  • consultation
    • 2022-09-20 Radiation Oncology
      • Q
        • This 72-year-old woman had past history of 1) infilltrating duct carcinoma of left breast, pT2N0M0, grade II ER: positive (90%), PR:40%, Her2/neu:equivocal (2+)–FISH NEGATIVE , P53(-), Ki- 67 index: 30%. post MRM (2013/10/17).
        • She received the chemotherapy with AC followed by hormone therapy on 2013 then was regularly followed up at ONC OPD. Bone scan on 2022/04/22 showed in comparison with the previous study on 2021/7/2, more new bone lesions are noted, suggesting multiple bone metastases in progression.Then she started the CDk4/6 inhibitor with Kisqali and Femara from July 2022 to August 2022. Hold due to leukopenia and general weakness.
      • A
        • A: Infiltrating ductal carcinoma, grade II, of the left breast, ER: positive (90%), PR:40%, Her2/neu:equivocal (2+, FISH: negative), stage pT2N0(cM0), s/p MRM and chemotherapy, with multiple including liver and bone metastases.
        • P: Radiotherapy is indicated for this patient with the following indicators: Bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
          • Goal: palliation
          • Treatment target and volume: whole brain including bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
          • Technique: 2D
          • Preliminary planning dose: 3000cGy/15 fractions of the whole brain including bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family (husband and son). They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-09-28.
    • 2022-09-08 Oral and Maxillofacial Surgery
      • Q
        • 20220819 Xgeva
        • However, gingiva swelling was noted today, we need your expertise for further management, thanks
      • A
        • For gingiva swelling
        • O:
          • Poor oral hygiene with lots of calculus was noted of full mouth.
          • Tenderness and swelling of right chin was noted.
          • Abscess with sinus tract of right anterior mandible. Pus discharged was noted. Residual root of 42 s/p RCF with gingiva inflammation was noted
          • Breast cancer under Xgeva treatment
        • A:
          • Periapical abscess with sinus tract of tooth 42
        • P:
          • Explained the finding to patient and her family.
          • Periodontal emergency of right mandible.
          • Suggest systemic antibiotics treatment.
          • OPD follow up
  • chemoimmunotherapy
    • 2022-10-07 ~ undergoing - Aromasin (exemestane)
    • 2022-10-07 ~ undergoing - Afinitor (everolimus)
    • 2022-03-25 ~ undergoing - Arimidex (anastrozole)
    • 2021-09-10 ~ 2022-03-29 - Kisqali (ribociclib)
    • 2021-07-16 ~ undergoing - Xgeva (denosumab)
    • 2017-01-06 ~ 2022-03-XX - Femara (letrozole)

==========

2022-11-21

  • The results of the uric acid lab showed an upward trend and indicated an increased risk of renal damage. It may be possible to consider Feburic (febuxostat 80mg) 0.5# QD without the need of adjusting the dose based on the current level of liver function.
    • 2022-11-18 Uric Acid 8.6 mg/dL
    • 2022-10-31 Uric Acid 6.7 mg/dL
    • 2022-09-30 Uric Acid 6.1 mg/dL

2022-10-26

  • Cell plasticity constitutes the ability of cancer cells to rapidly reprogramme their gene expression repertoire, to change their behaviour and identities, and to adapt to microenvironmental cues. These features also directly contribute to tumour heterogeneity and are critical for malignant tumour progression. (ref: Breast cancer as an example of tumour heterogeneity and tumour cell plasticity during malignant progression. Br J Cancer 125, 164–175 (2021). https://doi.org/10.1038/s41416-021-01328-7). It is likely that the available gene assay results “ER:positive (90%), PR:40%, Her2/neu:equivocal(2+, FISH negative), P53(-), Ki-67 index 30%” were obtained long ago (MRM in 2013). A new gene expression assay might be beneficial.
  • The use of Aromasin (exemestane) and Afinitor (everolimus) has been started since Oct 2022 after a CT image (Sep 2022) indicated that the disease was in progress.
  • It does not appear that there is a problem with the active prescription.

700569043

221118

{drug identification}

It was requested that four drugs be identified.

The items identified are as follows:

  • Lipanthyl Supra (fenofibrate 160mg)
  • Trajenta (linagliptin 5mg)
  • Crestor (rosuvastatin 10mg)
  • Bentomin (metformin 500mg)

These drugs will be sent back to ward by an in-hospital porter.

701196725

221118

  • diagnosis - 2022-11-04 discharge note
    • Colon adenocarcinoma with obstruction s/p right hemicolectomy on 2021/12/01, pT4aN2bcM0(7/15), G2, LVI(+), PNI(+), CRM(-), stage IVA with liver metastasis s/p chemotherapy with Avastin(5mg/kg)(self pay)/FOLFIRI(Campto 120mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) from 2022/03/18~2022/05/26 for 4 cycles, patient refuse therapy with bilateral lungs, pleura, liver, peritoneal and retroperitoneal metastases s/p palliative chemotherapy with FOLFIRI from 2022/09/12
    • Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
    • Essential (primary) hypertension
    • Unspecified hemorrhoids
  • exam finding
    • 2022-11-02 CT - abdomen
      • History:
        • 20211120 CT:Dilatation of small bowel and collapse of colon, r/o obstruction at ileocecal valve. Suspect wall thickening of terminal ileum and Small bowel feces sign in distal ileum +.
        • 20211124 colonoscopy: One ulcerative tumor with about 1/2 circumferential involvement at ICV and extending to A-colon.
        • 20211201 S/P right hemicolectomy:pT4aN2b, if cM0, stage IIIC
        • 20220712 CT:Peritoneal carcinomatosis, lung and liver metastases.
      • Findings:
        • Prior CT identified multiple hypodense masses on both hepatic lobes are noted again, increasing in size and number that are c/w liver metastases with progressive disease.
        • Prior CT identified few metastases on both lung are noted again, mild increasing in size that is c/w progressive disease.
        • There is massive ascites and soft tissue nodules in the omentum and mesentery that is c/w carcinomatosis. Please correlate with ascites cytology.
        • S/P right hemicolectomy
        • Few small gallstones are noted.
        • There is no hyper-or hypodense lesion in the biliary system, pancreas, spleen & both kidney.
        • There is no lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
      • IMP:
        • Peritoneal carcinomatosis, lung and liver metastases show progressive disease.
    • 2022-09-27 All-RAS + BRAF mutations assay
      • All-RAS mutations assay
        • Detection range
          • KRAS codon 12, 13, 59, 61, 117, 146
          • NRAS codon 12, 13, 59, 61, 117, 146
        • Results
          • Detected (KRAS codon 12 GGT>GAT, p.G12D)
        • Interpretation
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
      • BRAF mutations assay
        • Detection range
          • BRAF codon 600: p.V600M, p.V600L, p.V600E, p.V600A, p.V600G, p.V600K, p.V600R
        • Results
          • There was no variant detected in the BRAF gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • 2022-09-06 SONO - abdomen
      • Chronic liver parenchymal disease
      • c/w liver and lymph node metastasis
      • Ascites
      • Minimal pleural effusion
    • 2022-09-05 Patho - stomach biopsy
      • Esophagus, 25 cm to EC junction, biopsy — Ulcer, with no viable tissues
      • Microscopically, it shows necrotic debris, granulation tissue,and abundant lymphocytic and leukocytic infiltrate. No viable tissue is seen.
      • Immunohisotchemical stain reveals CK(-), CD20(-), CD3(-), LAC(focal+),and CMV(-).
    • 2022-09-05 Patho - stomach biopsy
      • Stomach, angle, biopsy — ulcer with Helicobacter infection
      • Microscopically, it shows ulcer with ulcerative debris, focal intestinal metaplasia and leukocytic infiltrate.
      • Mild Helicobacter-like bacilli are seen.
    • 2022-09-02 CXR
      • Tortous aorta with calcification is noted.
      • Increased pulmonary vasculature is found.
    • 2022-09-02 KUB
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • Stool impaction at the abdominal cavity is noted.
    • 2022-09-02 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis with ulceration, LA-D
        • Superficial gastritis, s/p CLO test
        • Gastric ulcer, angle, s/p biopsy*4
        • CLO test (+)
      • Suggestion
        • PPI pump and algitab
        • Pursue pathology
        • GI OPD for HP eradication after discharge
    • 2022-07-12 CT - abdomen
      • Findings
        • S/P colon operation.
        • A nodule (5.4mm) at LLL.
        • Some soft tissues in peritoneal cavity with ascites.
        • Multiple liver tumors.
        • Some calcifications in peritoneal cavity.
        • Normal appearance of spleen, pancreas, adrenals and kidneys.
        • Tiny gallbladder stones.
        • Intact bony structures.
        • No enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
      • IMP:
        • S/P colon operation. Peritoneal carcinomatosis, lung and liver metastases.
    • 2022-05-27 SONO - abdomen
      • Diagnosis
        • Liver cirrhosis with borderline splenomegaly
        • Hepatic hypoechoic lesions, multiple, both lobe, suspected metastases
        • Gallbladder polyp
        • Cholecystopathy
        • Small amount ascites
      • Suggestion
        • Please correlate with other image study
    • 2022-03-01 CT - abodmen, pelvis
      • Clinical history: 71 y/o male patient with cecal cancer s/p OP and C/T.
      • Findings
        • S/P right colectomy with regional dirty mesentery fat plane, post-op change? Suggest follow up.
        • There are several low density tumors (up to 1.4cm) in both lobes of the liver, suspected liver metastasis.
        • Presence of gallbladder stone.
      • Impression:
        • S/P right hemicolectomy with regional dirty mesentery fat plane, post-op change? Suggest follow up.
        • Liver tumors, suspect liver metastasis.
    • 2021-12-02 Patho - colon segmental resection for tumor
      • PATHOLOGIC DIAGNOSIS
          1. Tumor, ascending colon, right hemicolectomy — Adenocarcinoma
          1. Resection margins, bilateral, ditto — Free from tumor
          1. Lymph node, mesocolic, dissection — Tumor metastasis (7/15) with extracapsular extension (3/7)
          1. Appendix, right hemicolectomy — Tumor emboli present, but no direct invasion
          1. AJCC pathologic stage — pT4aN2b, if cM0, stage IIIC
      • MICROSCOPIC EXAMINATION
          1. Histology: adenocarcinoma
          1. Histology Grade: G2-3: moderately to poorly differentiated
          1. Depth of invasion: visceral peritoneum and some tiny nodules at ileal wall
          1. Angiolymphatic invasion: Present
          1. Perineural invasion: Present
          1. Discontinuous extramural tumor extension: NOT identified
          1. Circumferential (radial) margin of rectosigmoid: NOT involved
          1. Lymph node metastasis, mesocolic: tumor metastasis (7/15)
          1. Lymph node metastasis, IMA / SMA: N/A
          1. Extranodal involvement: Present (3/7)
          1. Pathological TNM Stage: pT4aN2b
          1. Type of polyp in which invasive carcinoma arose: N/A
          1. Additional pathologic findings: focal tumor necrosis
          1. TNM descriptors: N/A
          1. Tumor regression grading S/P CCRT: N/A
    • 2021-11-26 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (162 - 47) / 162 = 70.99%
        • Dilated LA, LV
        • Adequate LV, RV systolic function with normal wall motion
        • Thick IVS, Impaired LV relaxation
        • Mild MR,TR,AR
    • 2021-11-25 Patho - colorectal polyp
      • Colon, ileocecal valve, biopsy — Adenocarcinoma, moderately differentiated
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2021-11-24 Colonoscopy
      • Diagnosis
        • Suspect advanced colon cancer, ICV, s/p biopsy(A), terminal ileum maybe involved.
        • Colon polyp, proximal T-colon, s/p cold polypectomy(B) and clip
        • Colon polyp, T-colon, s/p hot polypectomy(C) and clip
        • ICV stenosis.
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2021-11-23 Small bowel series
      • Small bowel dilatation, suspected partial obstruction at distal small bowel. Suggest clinical correlation
    • 2021-11-20 CT - abdomen
      • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4(T_value) N:N2(N_value) M:M0(M_value)
    • 2021-11-20 KUB
      • Dilatation of small bowel and collapse of colon, suspected obstruction
    • 2021-11-20 ECG
      • Sinus tachycardia
      • Right bundle branch block
    • 2021-11-11 Abdomen - standing (diaphragm)
      • Stool retention in the colon
    • 2021-11-05 Small Intestinal Series
      • Normal haustration of the jejunum and ileum.
      • The peristasis of the small intestine is intact.
      • No evidence of stenotic or obstructive lesion in the study.
      • The transit time is 4 hours
    • 2021-11-04 Abdomen - standing (diaphragm)
      • Presence of ileus.
    • 2021-11-02 CT - abdomen
      • Dilated intestines and colon, suspected enterocolitis
    • 2021-11-02 KUB
      • Dilated bowel gas, suspect ileus. Degenerative change of the spine with marginal spur formation. Calcified nodules in the pelvic cavity, could be urinary bladder stone.
    • 2021-11-02 ECG (emergency)
      • Sinus tachycardia
      • Right bundle branch block
      • Minimal voltage criteria for LVH, may be normal variant
      • T wave abnormality, consider inferolateral ischemia
    • 2019-09-24 ECG
      • Right bundle branch block
      • Nonspecific T wave abnormality
  • consultation
    • 2021-11-25 Colon and Rectal Surgery
      • Q
        • This is a 70-year-old male patient with the underlying diseases DM, HCVD under medicine control. This time, he is presented with LUQ abdominal pain and fullness, nausea sensation, no stool passage, and intermittent fever for 2 days .
        • He had ileus on 20211103, and AAD on 20211105 under small serious normal. Under the impression of ileus again, he came to our ward to do further management and examination.
        • On 20211120 abdominal CT, Small bowel dilatation, suspected obstruction, Suspect wall thickening of terminal ileum with regional lymphadenopathy.
        • On 20211124 colonscope found suspect advanced colon cancer, ICV, s/p biopsy, terminal ileum maybe involved.
        • We had arranged him to do 2D heart echo and PFT.
      • A
        • A: Tumor of cecum with partial obstruction
        • P: The operaion of right hemicolectomy is indicated
    • 2021-11-22 General and Gastroenterological Surgery
      • Q
        • This is his second-time intestinal ileus, so we would like to consult your expertise for him. Does he need the surgery survey?
      • A
        • A: ileus, suspected colonic lesion ot terminal ileum lesion with mechanical obstruction
        • P: Please arrange colonoscopy to rule out colonic lesion ot terminal ileum lesion. If no colonic lesion ot terminal ileum lesion, but symptoms persisted, laparoscopy exam may be considered.
  • chemoimmunotherapy
    • 2022-11-17 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-11-02 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-10-17 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-09-27 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-09-12 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-08-16 ~ 2022-08-30 - UFT (tegafur 100mg, uracil 224mg)/cap 2# BID PO
    • 2022-06-14 ~ 2022-08-09 - Xeloda (capecitabine 500mg/tab) 1# TID PO
    • 2022-05-26 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-04-25 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-03-18 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-02-23 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
    • 2022-02-09 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
    • 2022-01-19 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
    • 2022-01-05 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)

==========

2022-11-18

  • CT imaging on 2022-11-02 revealed peritoneal carcinomatosis and lung and liver metastases and a progressive disease was present.
  • In the past two months, more than 10 kg of weight have been lost (63 kg 2022-11-17 <- 74 kg 2022-09-22). The use of appetite stimulants (e.g. megestrol) may be beneficial.
  • Based on the updated elevated bilirubin levels, there are no issues associated with the irinotecan dose.

2022-10-18

  • The patient with mCRC has received FOLFOX/FOLFIRI plus bevacizumab since early 2022.
  • Regorafenib might be an option as a subsequent treatment if the patient’s disease becomes resistant, and would be covered by the national health insurance program without prior use of cetuximab or panitumumab due to the detected KRAS mutation (2022-09-27 All-RAS + BRAF mutations assay). Regorafenib does not require dosage adjustment in patients with mild or moderate hepatic impairment (total bilirubin 1.79mg/dL 2022-10-11 < 3 times ULN), closely monitor for adverse effects. The drug can be administered orally 160 mg once daily for the first 21 days of each 28-day cycle; continue until disease progression or unacceptable toxicity.
  • Lonsurf (trifluridine/tipiracil) is also covered by NHI, however the drug is not recommended for this patient due to his total bilirubin > 1.5 times ULN.

2022-09-28

  • The serum glucose level remains within acceptable limits with the use of patient-carried Uformin (metformin), Amepiride (glimepiride), and Januvia (sitagliptin).
  • Human albumin is used to treat hypoalbuminemia (3.2g/dL 2022-09-22) associated with liver cirrhosis (ABD Sono 2022-09-06).
  • The total bilirubin level was 1.51mg/dL (above 1.5 x ULN, 2022-09-22); the treated dose of irinotecan was 150mg/m2 (2022-09-27), not exceeding the recommended limit of 200mg/m2.

701446396

221118

  • diagnosis
    • Right ovarian cancer (Clear cell adenocarcinoma) pT1a pN0 ; AJCC/FIGO pStage: IA, at least. post debulking surgery on 2022/08/26
    • Unspecified viral hepatitis B without hepatic coma.
  • exam findings
    • 2022-11-09 SONO - breast
      • Diagnosis: Bil. fibroadenomas
      • Suggestion: regular OPD follow up
      • BI-RADS: 2. benign finding
    • 2022-11-02 Mammography
      • Impression: Dense breast. Probably benign calcifications in bilateral breasts. Suggest clinical correlation and follow up.
      • BI-RADS: Category 2: benign findings.-annual screening.
    • 2022-08-29 Patho - soft tissue tumor, extensive resection
      • Ovarian Fallopian tube Peritoneum Cancer Checklist (Based on AJCC 8th ed. and FIGO 2014)
      • PATHOLOGIC DIAGNOSIS
        • Ovary, right, oophorectomy with frozen section (F2022-400) — Clear cell adenocarcinoma, high grade.
          • IHC stains: Napsin-A (+), P53: (wild type), PAX-8 (+), CK20 (-), ER (-, 0%)
        • Ovary, left , salpingectomy (S2022-14311) — Free.
        • Fallopian tube, right, salpingectomy — Free
        • Fallopian tube, left, salpingectomy — free
        • Uterus, corpus, total hysterectomy — myoma; No malignancy.
        • Uterus, cervix, total hysterectomy — free
        • Omentume, omentectomy — free
        • Lymph node, dissection — free
        • pT1a pN0 (if cM0); AJCC/FIGO pStage: IA, at least.
          • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated. Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • MICROSCOPIC EXAMINATION:
        • Histologic type: clear cell adenocarcinoma
        • Histologic grade: ghigh grade
        • Contralateral ovary involvement: absent
        • Tumor side ovarian surface involvement: absent
        • Contralateral ovary surface involvement: absent
        • Right tube involvement: absent
        • Left tube involvement: absent
        • In situ adenocarcinoma in right and/or left fallopian tube: absent
        • Right adnexa soft tissue involvement: absent
        • Left adnexa soft tissue involvement: absent
        • Pelvic soft tissue involvement: absent
        • Uterine serosa involvement: absent
        • Omentum involvement: absent
        • Uterine Cervix involvement: absent
        • Endometrium involvement: absent
        • Myometrium involvement: absent
        • Appendix involvement: not received
        • Largest Extrapelvic Peritoneal Focus - none
        • Peritoneal/Ascitic Fluid-Negative for malignancy (normal/benign)
        • Regional Lymph Nodes: - free
        • Other organs or specimens involvement: none.
    • 2022-08-26 Frozen section
      • Preliminary diagnosis: right ovary: malignant
    • 2022-08-26 Patho - stomach biopsy
      • Gastric polyp, cardia, biopsy — Compatible with fundic gland polyp
    • 2022-08-24 ECG
      • Normal sinus rhythm
      • Possible Left atrial enlargement
      • Septal infarct, age undetermined
      • Abnormal ECG
    • 2022-08-15 CT - abdomen
      • Findings
        • Cystic tumor, 13.8cm in the pelvic cavity, with soft tissue component, suspected right ovarian malignancy.
        • Liver cyst, 0.77cm in S2.
        • Soft tissue tumor, 2.7cm in the uterine fundus region, suspected uterine myoma.
      • Imaging Report Form for Ovarian Carcinoma
        • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia (Stage_value)
    • 2022-08-15 Gynecologic ultrasonography
      • Suspected pelvis mass: 109X75mm with papillary: 25x19mm
      • Suspected pelvis mass or uterine myoma: 98x77, RI: 0.47
      • Adenomyosis
  • consultation
    • 2022-10-28 Chinese Medicine
      • Q
        • The 59 y/o woman has right ovarian cancer (Clear cell adenocarcinoma) pT1a pN0 ; AJCC/FIGO pStage: IA, at least. post debulking surgery on 2022/08/26. She was admitted for chemotherapy. She asks for your help for assessment.
  • surgical operation
    • 2022-08-26 debulking surgery (total abdominal hysterectomy + bil salpingo-oophorectomy + BPLND + partial omentectomy) + enterolysis
      • uterus and bil adnexa
        • Uterus: 12x8x5 cm
        • corpus – adenomyosis-like with some uterine myomas
        • cervix – seemed free of cancer invasion
        • right adnexa –
        • ROV 15x14cm tumor with large solid and cystic contents, containing chocolate fluid 600 c.c
        • Frozen section of ROV–malignancy
        • right tube – np
        • left adnexa: normal-looking
        • bowels, omentum, liver– seemed free of cancer invasion
        • Bilateral pelvic iliac and obturator LNs was removed
        • left iliac LNs
        • left obturator LNs
        • right iliac LNs
        • right obturator LNs
        • CDS: no ascites (washing cytology was sent) but pelvic adhesion was noted between right adnexa, pelvis, peritoneum and bowels s/p enterolysis A 7mm JP drain was placed in CDS
  • chemoimmunotherapy
    • 2022-11-17 paclitaxel 175mg/m2 268mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-10-27 paclitaxel 175mg/m2 268mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-10-06 paclitaxel 160mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr (paclitaxel first time 160, next 175)

[assessment]

  • The lab results (2022-11-17) were grossly normal and should be considered satisfactory for the scheduled chemotherapy.
  • The currently used [paclitaxel + cisplatin] regimen is preferable since carboplatin produces equivalent response rates and survival outcomes to cisplatin and is associated with less toxicity, while paclitaxel is less myelosuppressive than docetaxel. There is, however, a higher risk of neuropathy, myalgias, and weakness associated with paclitaxel in comparison with docetaxel, which should be monitored regularly.
  • The underlying condition of viral hepatitis B is appropriately managed with Vemlidy (tenofvir alafenamide).

701262855

221117

{drug identification}

requesting drug identification for 6 items.

the 5 items are identified as following while the other 1 item remains unknown.

Indershin (indomethacin 25mg) Anrokin (chlorzoxazone 200mg) Leflo (levofloxacin 500mg) Ketofen (ketoprofen 50mg) Decan (dexamethasone 0.75mg)

The drugs were packaged as one dose in an opaque bag, which was opened irreversibly. The checked drugs will not be returned to the ward due to the possibility of contamination.

700399143

221116

  • exam findings
    • 2022-11-03, -10-30, -10-27 CXR
      • Massive right side Pleura effusion causing mediastinum shift to left side.
      • There are patchy opacity on right lung and nodular opacity projecting in left lung. Please correlate with CT.
    • 2022-10-27 CT - chest
      • Indication: Malignant neoplasm of right main bronchusLung cancer, clinical trail
      • Findings
        • Huge soft tissue mass at right lung up to 16.cm with massive right pleural effusion is found. In enlargement.
        • Left lung nodules are found up to 1.7cm in largest dimension is found. In comparison with CT dated on 2022-09-12, the lesion enlarged markedly.
        • Marked paraseptal Emphysematous change over both lungs more on upper lobes is found.
        • Right axillary lymphadenopathy is found.
      • Imp:
        • Huge right lung cancer with lung to lung meta, right axillary lymphadenopathy, in progression.
    • 2022-10-06 ROS1 FISH
      • Result
        • Number of invasive tumor cells counted: 50
        • Number of cells (%) classified as negative: 49 (98%)
        • Number of cells (%) classified as positive: 1 (2%)
      • Interpretation
        • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
    • 2022-10-06 ALK IHC
      • ALK immunostaining result: Negative
      • The immunostaining of the section slide labeled S2022-15576, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining in tumor cells.
    • 2022-10-04 MRI - brain
      • No intracranial metastatic lesion.
    • 2022-09-27 Tc-99m MDP whole body bone scan with SPECT
      • Mildly increased activity in some L-spines and sacrum. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
    • 2022-09-22 PD-L1 (22C3)
      • PD-L1 immunostaining result
      • Tumor Proportion Score (TPS) assessment: >= 50%
      • Tumor Proportion Score (TPS): 85%
    • 2022-09-22 EGFR mutation
      • Result: No mutation was detected at exons 18 (G719X), 19 (Deletions), 20 (T790M, S768I, Insertions), 21 (L858R, L861Q) of EGFR gene in this specimen.
    • 2022-09-15 Patho - bronchus biopsy
      • Lung, RLL, CT-guide biopsy — poorly differentiated non-small cell carcinoma, origin?
      • Sections show large pleomorphic tumor cells infiltrating in a fibrotic stroma with marked tumor necrosis.
      • The immunohistochemical stains reveal CK7(+), CK20(-), CK5/6(-), GATA3(+), CDX2(focal weak +), TTF-1(-), Napsin A(-), CD56(-), and p40(-). Please correlate with the clinical presentation and image study to exclude other tumor origin.
    • 2022-09-12 CT - chest
      • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1a(M_value) STAGE:____(Stage_value)
    • 2022-09-12 CXR
      • Huge mass lesion over right lung. Suggest check CT scan.
    • 2022-08-01 T-spine AP + Lat.
      • Large patchy consolidation over RUL.
  • chemoimmunotherapy
    • 2022-11-03 - pembrolizumab 100mg 1hr
    • 2022-10-31 - carboplatin AUC 2 300mg 2hr D1 + paclitaxel 80mg/m2 120mg 1hr D2

[assessment, not posted]

  • There were no mutations or arrangements detected for EGFR, ALK, or ROS1. There is a tumor proportion score of 85% greater than 50% for PD-L1. In this case, the [carboplatin + paclitaxel + pembrolizumab] regimen is appropriate.

700016065

221115

  • diagnosis - 20221114 admission note
    • Malignant neoplasm of esophagus, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Chronic hepatitis, unspecified
    • Unspecified cirrhosis of liver
  • past history - 20221114 admission note
    • HBV and alcohol related to liver cirrhosis, Episode hepatic encephalopathy times on 2009
    • Hemorroid bleeding on 2009.05
    • Reflux esophagitis, gastric ulcer, duodenal ulcer and esophageal varices history for years
    • CAD under medication treatment for months
  • exam findings
    • 2022-11-08 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
      • Poor echo window due to inter-position of colon between liver and abdominal wall
      • Collateral vessels, splenic hilum
    • 2022-09-22 Miniprobe Endoscopic Ultrasound
      • Esophageal cancer, middle and lower esophagus, T3 (suspicioius N1) Mx
    • 2022-09-21 Tc-99m MDP whole body bone scan with SPECT
      • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, bilateral sternoclaviculr junctions, shoulders, S-I joints, hips, and left knee.
    • 2022-09-06 Patho - esophageal biopsy
      • Esophagus, 30 cm below incisor, biopsy — modertaely differentiated squampus cell carcinoma
      • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of squamous tumor cells in infiltrative growth pattern. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • 2022-09-05 Panendoscopy
      • Esophageal cancer, middle esophagus, s/p biopsy
      • Advance esophageal lesion, middle and lower esophagus
      • Reflux esophagitis, lower esophagus, LA classification, grade B
      • Superfical gastritis, antrum
    • 2022-03-07 CT - abdomen
      • Indication
        • Alcoholic + HBV related, Liver cirrhous with hepatic encephalopathy
        • 2021/12/20: echo and lab stable, follow up 3 months later by lab and CT
      • Findings
        • Severe splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
        • Significant splenic varices formation with splenorenal shunt is also noted.
      • Imp
        • Liver cirrhosis with varices formation and splenorenal shunt
        • No evidence of hepatic tumor in the study.
    • 2021-06-29 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
      • Colleteral vessels, LUQ of abdomen
    • 2021-04-05 CT - abdomen
      • Liver cirrhosis with portal hypertension, left splenorenal shunt and splenomegaly.
      • Much stool retention in colon.
    • 2020-05-06 CT - abdomen
      • Liver cirrhosis with splenomegaly and varices formation.
      • No evidence of hepatic tumor in the study.
    • 2019-11-19 SONO - abdomen
      • Cirrhosis of liver
      • Part of right lobe masked by gas
      • Splenomegaly, mild
    • 2019-08-27 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
      • Spleno-renal shunt
    • 2019-05-31 CT - abdomen
      • Liver cirrhosis and portal hypertension.
      • Splenomegaly.
    • 2019-03-19 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
    • 2018-07-05 CT - abdomen
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2017-08-02 CT - abdomen
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2017-02-17 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 31) / 118 = 73.73%
        • M-mode (Teichholz) = 73
      • Septal hypertrophy with Gr I LV diastolic dysfunction; dilated LA.
      • Normal LV and RV systolic function.
      • Mild MR; mild TR.
      • VPC bigeminy.

[assessment]

  • Metoclopramide is recommended to be given at a dose of 5 mg four times daily (maximum dose: 20 mg) for patients with moderate or severe hepatic impairment (Child-Pugh class B or C). The medication is currently prescribed in both oral and IV forms, with a dose of 3.84mg PO TIDAC and 10mg IVD PRNQ6H.
  • As far as morphine for patients with hepatic impairment is concerned, the manufacturer’s labeling does not provide any dosage adjustments. Pharmacokinetics remain unchanged in mild liver disease; substantial extrahepatic metabolism may occur. There may be a need to adjust the dosage in patients with cirrhosis due to increases in half-life and AUC.
  • A dose adjustment is not required for any other drug in the active prescription.

700054842

221115

  • exam findings
    • 2022-11-09 CT - abdomen
      • Indication: liver mass
      • CC:
        • Nausea and diarrhea for 2 weeks. Dizziness.
        • Abdominal fullness and passage of black stools for 2 weeks.
        • Tea-colored urine was noted. Tense leg edema for 10 days.
      • Past history:
        • An oral caner patient and received operations and RT since 2013/2/15. He has sleeping problem and abnormal taste in his mouth after operation and RT. He quit betel nut chewing and smoking in his past years. He had been received induction chemotherapy, operations and adjuvant RT due to oral cancer at his left lower gum since 2011/11.
      • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
      • Findings:
        • There is hepatomegaly (the greatest cranial-caudal dimension measuring 21.2 cm) and infiltrative hypodense masses on both hepatic lobes.
          • Metastases on both hepatic lobes are highly suspected.
          • The tumor margin is hard to define in non-enhanced CT. Please correlate with contrast enhanced dynamic CT or non-enhanced MRI.
          • In addition, There is minimal dilatation of right lobe inferior segment IHDs that may be tumor compression.
          • Please correlate with serum alk-p and bilirubin level.
        • There is a soft tissue lesion in left para-aortic space, 2.2 cm in size that may be metastatic node (Srs:201 Img:26) .
        • There is ascites.
        • There is lack of subcutaneous fat that may be cachexia status and hypoalbuminemia.
        • A renal cyst measuring 1.9 cm in right middle pole is noted.
        • There is no hyper-or hypodense lesion in the gallbladder, , pancreas, spleen & left kidney.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • IMP:
        • Metastases on both hepatic lobes are highly suspected.
        • Metastatic node in left para-aortic space 2.2 cm.
        • Ascites
    • 2022-11-04 SONO - abdomen
      • Diagnosis
        • Liver tumor, right lobe, suspicious HCC with main and right portal vein encasement.
        • Liver hemangioma, S2
        • Renal cyst, right
        • Ascites, mild
      • Suggestion
        • arrange liver dynamic CT and correlate with tumor markers.
    • 2022-08-16 KUB and lateral L-spine
      • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • 2019-05-28 MRI - nasopharynx
      • Post OP at left oral cavity and mandible, stationary.
    • 2018-08-03 MRI - nasopharynx
      • Prominent soft tissu in the right lower gingiva. Nature?
    • 2017-11-24 MRI - L-spine
      • mild retrolisthesis at L2-3.
      • herniated discs in the L2/3 and L3/4 discs
      • annulus tears in the L4/5 and L5/S1 discs
    • 2017-11-23 MRI - nasopharynx
      • Post flap reconstruction surgery at left anterior lower buccal-gingival region, mandible and submental region with sof-tissue tissue defect, and retention of surgical clips. As compared with previous study on 2017/04/11, there was no interval change. No focal mass or nodule.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
    • 2017-04-11 MRI - nasopharynx
      • Post flap reconstruction surgery at left anterior lower buccal-gingival mandible regions with left neck LNs dissection. No evidence of tumor recurrence.

700312743

221115

{gastric signet-ring cell carcinoma}

  • exam findings
    • 2022-11-13 CXR
      • Consolidations in both lung fields
      • Normal heart size and configuration
      • Suspect left pleural effusion
    • 2022-11-09 SONO - chest
      • Finding
        • Left-side of thorax
          • Irregularly thickened pleurae was noted along with moderate free and anaechoic effusion LLL consolidaiton and atelectasis
        • Right-side of thorax
          • no pleural effusion
          • No active lung lesion
      • Echo diagnosis:
        • Pleural effusion, moderate, left
        • atelectasis, LLL
        • Pleural nodules, left
    • 2022-11-08 Pelvis & Lt. Hip Lat
      • Avascular necrosis of right femoral head is highly suspected. please correlate with clinical condition and MRI.
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • 2022-11-08, -10-31 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-11-04 CT - chest
      • Bil. pleural effusion with adjacent lung collapse.
      • No evidence of pulmonary embolism.
    • 2022-10-28 Panendoscopy
      • Diagnosis
        • Esophageal mucosal oozing, s/p hemostasis with APC
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis, remnant stomach
        • c/w s/p antrectomy with B-II anastomosis
      • Suggestion
        • High dose PPI * 3 days
    • 2020-10-26 CT - abdomen
      • History:
        • 20200729 BW loss 6 Kgs in recent 6 months, postprandial epigastric discomfort and poor appetie for 3 months
        • 20200729 Gastroscopy: Borrmann type II gastric cancer in the antrum. CT staging: cT4aN2M0, cSTAGE:III
        • 20200810 S/P subtotal gastrectomy: Tumor present at greater omentum. Surgeon suggests tumor seeding and c/w distant metastasis. pT4aN3aM1, pstage IV
      • Indication: LUQ pain persist in recent months
      • Findings:
        • There is left side Pleura effusion with suggstive thickening at the parietal pleura that may be pleura tumor seeding. Please correlate with pleura biopsy and pleura effusion cytology.
          • In addition, There are multiple enlarged nodes in paratracheal space, subaortic space, bilateral hilum and subcarina space that are c/w metastatic nodes.
        • S/P subtotal gastrectomy
        • Prior CT identified Mild soft tissue density lesion in the celiac trunk surrounding area is noted again, stationary that may be normal variation.
          • The differential diagnosis include metastatic nodes. Follow up is indicated.
        • There are several hepatic cysts in both lobes and the largest one 1.3 cm in size at S7.
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • There is left side Pleura effusion with suggstive thickening at the parietal pleura that may be pleura tumor seeding. Please correlate with pleura biopsy and pleura effusion cytology.
        • Metastatic nodes in the mediastinum are noted.
    • 2022-10-12 Patho - pleural/pericardial biopsy
      • Pleura, left, biopsy — metastatic signet-ring cell carcinoma, consistent with gastric origin
      • Section shows skeletal muscle fibers and fibroadipose tissue with metastatic signet-ring cell carcinoma.
      • The immunojostochemical stains reveal CK(+), CDX2(+), Calretinin(-), and TTF-1(-). The results are consistent with gastric origin.
      • The immunohistohcmeical of Her-2/neu (Ab) is done and shows Negative (0).
    • 2022-10-11 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 27) / 89 = 69.66%
        • LVEF (%) = 70
        • M-mode (Teichholz) = 70
      • Normal LV systolic function with normal wall motion.
      • Impaired LV relaxation.
      • Normal RV systolic function.
      • Mild MR; moderate TR; mild PR; aortic valve sclerosis.
      • Possible mild pulmonary hypertension, estimated PASP: 36 mmHg.
      • Flat IVC and tachycardia; consider hypovolemia.
      • Left pleural effusion.
    • 2022-09-24 CT - abdomen
      • Indication
        • [ICD10CM] Malignant neoplasm of pyloric antrum
        • [ICD10CM] Malignant neoplasm of stomach, unspecified
      • Findings
        • s/p partial gastrectomy.
        • The GB is well distended without soft tissue lesion
        • Minimal soft tissue mass around the celiac trunk is found. In comparison with CT dated on 2022-07-18, the lesion is stationary.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
        • Non-specific bowel gas at abdominal cavity is found.
        • Dilated CBD is found. Stationary.
        • Massive left pleural effusion is found.
        • Normal heart size.
        • The lung fields are clear.
      • Imp:
        • s/p partial gastrectomy.
        • Minimal soft tissue mass around the celiac trunk is found. In comparison with CT dated on 2022-07-18, the lesion is stationary.
    • 2022-07-18 CT - abdomen
      • s/p subtotal gastrectomy.
      • Soft tissue mass surrounding the celiac trunk is found. In comparison with CT dated on 2022-04-20, the soft tissue is stationary in size and extention.
      • Increased intestinal gas is found. The intestines are wall dilated. Post op. change is favored.
    • 2022-04-28 MRI - T-spine
      • The thoracic spine shows normal alignment and vertebral contour.
      • The thoracic disk spaces show no disk bulging, extrusion or protrusion.
      • The thoracic spinal cord shows normal size and signal intensity without evidence of compressive edema, ischemia or myelomalacia. There is no extrinsic compresson of the cord.
      • The neural foramina of the thoracic spine are patent. No impingement is seen.
    • 2022-04-27 Whole body PET scan
      • Glucose hypermetabolism in the LUQ of abdomen, compatible with S/P subtotal gastrectomy.
      • Glucose hypermetabolism in the soft tissue in the left supra-renal region and in the pre-vertebral space of T12 spine, the nature is to be determined (reactive nodes, metastatic lymph nodes or others ?), suggesting further investigation.
      • Glucose hypermetabolism in the right submandibular lymph nodes, the nature is to be determined also (reactive nodes or others ?), suggesting further investigation.
      • No prominent abnormal focal FDG uptake is noted elsewhere.
    • 2022-04-25 SONO - abdomen
      • Findings
        • Anechoic nodules, 1.19x0.65cm and 1.29x0.96cm in left lobe, 1.2x0.68cm and 1.07x0.85cm in right lobe, suspected liver cysts.
        • Normal appearance of gallbladder without stone.
        • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Impression
        • Liver cysts.
    • 2022-04-20 CT - abdomen
      • S/P subtotal gastrectomy.
      • Prior CT identified Mild soft tissue density lesion in the celiac trunk surrounding area is noted again, stationary that may be normal variation.
      • The differential diagnosis include metastatic nodes.
    • 2022-03-31 MRI - L-spine
      • Thoracicolumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, es T10-11-12 (with left OYL) and L4-5 (with Gr I spondylolisthesis).
    • 2022-01-27 CT - abdomen
      • S/P gastric operation. No evidence of tumor recurrence.
    • 2022-01-26 Tc-99m MDP whole body bone scan
      • Faint hot spots in the left fronto-parietal region of skull and right hip joint, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
      • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, and knees.
    • 2021-11-08 SONO - abdomen
      • Findings
        • Anechoic nodules, 1.22x0.7cm, 1.29x1.16cm and 1.14x0.98cm in left lobe, 0.96x0.51cm and 1.47x0.85cm in right lobe, could be due to liver cysts.
        • Normal appearance of gallbladder without stone.
        • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Impression:
        • Liver cysts.
    • 2021-08-16 CT - abdomen
      • S/P gastric operation. No evidence of tumor recurrence.
      • Liver cysts (up to 1.1cm).
    • 2021-03-09 CT - abdomen
      • s/p subtotal gastrectomy.
      • No evidence of recurrent/residual tumor in the study.
    • 2020-08-11 Patho - stomach subtotal/total (tumor)
      • Addendum:
        • Tumor present at greater omentum. Surgeon suggests tumor seeding and compatible with distant metastasis in clinico-pathologic conference.
        • AJCC pathologic staging is revised to pT4aN3aM1, stage IV
      • PATHOLOGIC DIAGNOSIS
        • Stomach, subtotal gastrectomy — Signet-ring cell carcinoma
        • Margins, bilateral cutting ends, ditto — Free of tumor
          invasion
        • MCA, ditto — Free of tumor metastasis (0/1)
        • Greater omentum, omentectomy — Tumor present
        • Lymph node, LN 1, dissection — Negative for tumor metastasis (0/1)
        • Lymph node, LN 3, ditto — Tumor metastasis (4/8) without extracapsular extension (0/4)
        • Lymph node, LN 4, ditto — Tumor metastasis (3/6) with extracapsular extension (2/3)
        • Lymph node, LN 5, ditto — Negative for tumor metastasis (0/4)
        • Lymph node, LN 6, ditto — Tumor metastasis (4/5) with extracapsular extension (1/4)
        • Lymph node, LN 7, 8, 9,12, ditto — Negative for tumor metastasis (0/3)
        • Lymph node, LN 11p, ditto — Negative for tumor metastasis (0/1)
        • Lymph node, LN 14, ditto — Tumor metastasis (3/3) with extracapsular extension (2/3)
        • AJCC Pathologic staging — pT4aN3a (if cM0), stage IIIB
      • MICROSCOPIC EXAMINATION
        • Histologic type: Signet-ring cell carcinoma
        • Histologic grade: Grade 3
        • Depth of tumor invasion: visceral peritoneum
        • Lymph nodes: tumor metastasis (14/31) with extracapsular extension (5/14) in total number
        • Omentum: Tumor present
        • AJCC Pathologic Staging: pT4aN3a
        • Bilateral Margins: Free of tumor invasion
        • Additional pathologic findings: intestinal metaplasia, focal mucin production
        • Immunohistochemical stains: CK(+), Her2(-, Dako score 0) for tumor cells
        • Perineural invasion: present
        • Lymphovascular space invasion: present
    • 2020-08-04 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 35) / 112 = 68.75%
        • M-mode (Teichholz) = 69
      • Dilated LA, Ao
      • Adequate LV,RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild TR, AR
    • 2020-07-29 Patho - stomach biopsy
      • Stomach, biopsy — Adenocarcinoma
      • Section shows fragments of gastric tissue infiltrated by isolated neoplastic cells.
    • 2020-07-29 CT - abdomen
      • History and Indication:
        • BW loss 6 Kgs in recent 6 months, postprandial epigastric discomfort and poor appetie for 3 months
        • 2020/07/29 Gastroscopy: Borrmann type II gastric cancer in the antrum. CT staging
      • FINDINGS:
        • There is lobulated wall thickening in the gastric antrum and low body and the maximal wall thickness measuring about 2.2 cm that is compatible with adenocarcionoma.
        • There are at least 4 enlarged nodes in the dorsal aspect mesentery of the perigastric antrum area (Srs:302, Img:38,43) that may be metastatic nodes in station 4 and 6.
        • Ascites in the pelvis is noted, nature?
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M0(M_value) STAGE:III (Stage_value)
    • 2020-07-29 Panendoscopy
      • big gastric ulcers. A2, highly suspected gastric cancer Bormman type II; antrum
  • consultation
    • 2022-10-17 ENT
      • Q
        • for hoarse throat days
        • This 67-year-old man, a patinet of gastric cancer with Gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p Op & HIPEC on 20200810 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T finishing in Oct 2020 & post-CCRT adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 11 finishing in May 2021. He was admitted due to dyspnea S/P pig-tail drainage inserted. He complained of hoarse throat for days. WE need expertise to evaluate his condition thanks!
      • A
        • Scope: smooth nasopharynx, oropharynx, hypopharynx. Fair vocal cord movement.
        • Impression: favor functional dysphonia.
        • Plan: May give Broen-C 2# TID.
        • ENT OPD follow-up after discharge.
    • 2022-08-12 Nephrology
      • Q
        • for hyponatremia,thanks
        • This 65-year-old male, a pt of gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p Op & HIPEC on 20200810, suffered from initial presentation of marked weight loss of 6kg from Feb 2020.
        • Surgical pathology with stomach, subtotal gastrectomy (20200810) proved signet-ring cell carcinoma.
        • Subtotal gastrectomy, BII anticolic anastomosis, D2 dissection, with T-colectomy and HIPEC with oxaliplatin 360mg/m2 (650mg) 42C for 60 min, on 20200810.
        • He was referred to our hemato-oncologic clinic on 20200901 for post-Op adjuvant CCRT & C/T.
        • We explain to pt & his wife about the indication & risk / benefit of post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-CCRT adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 12.
        • HBsAg, anti-HCV (20200901): negative.
        • #1 R/T to gastric tumor bed on 9/14 20
        • #1 post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T on 9/16~9/18 20, #2 on 9/28 20, #3 on 10/12 20.
        • #1 post-Op adjuvant CCRT with Oxaliplatin / HDFL IV Q2W x 12 on 11/17 20, #2 on 12/14 20, #3 on 12/28 20, #4 on 1/11 21, #5 on 1/25 21, #6 on 2/22 21, #7 on 3/15 21, #8 on 3/29 21, #9 on 4/12 21, #10 on 4/27 21, #11 on 5/11 21
        • The whole abdominal CT (3/9 21) showed s/p subtotal gastrectomy. No evidence of recurrent/residual tumor in the study.
        • Painless gastroscopy (4/1 21): Erosive reflux esophagitis LA Classification grade A
        • S/p subtotal gastrectomy with B-II anastomsis, superficial gastritis, remnant stomach.
        • Followed CXR & abd sono (11/8 21): negative but liver cysts.
        • Followed Abd CT (8/16 21) (1/27 22) revealeds/p gastric Op. No evidence of tumor recurrence.Liver cysts (up to 1.1cm).
        • Followed Abd CT (4/20 22)revealed s/p subtotal gastrectomy.Prior CT identified Mild soft tissue lesion in the celiac trunk noted again, stationary that may be normal variation. D/D include mets nodes.
        • PET scan (4/27 22) showed negative.
        • Followed Abd CT (7/18 22) revealed s/p subtotal gastrectomy.Soft tissue mass at the celiac trunk, compared wt CT on 4/20 22, the soft tissue is stationary in size and extention. c/o L lower chest wall pain. Dr Wu did bone scan.
        • Bone scan (1/26 22) showed negative. (2/8 22).
        • He complained of back pain & left lower abdominal discomfort, Dr Wu consult Dr Chang for CCRT on 7/26 22. Palliative R/T to recurrnet LAPs for 3500cGy/14 fractions is suggested for pain control. Suggest concurrent chemotherapy.The radiotherapy started on 8/5 22
        • This time ,he was admitted for #1 CCRT wt 5-FU 24 hr QD x 5 per wk x 3 on 8/9 22
        • However, hyponatremia was noted during CCRT.3% NACL 15ml/hr was administered. Followed the thyroid function and pending. We need your epertise for further management,thanks
      • A
        • This 65 years old male patient had underlying history of gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p subtotal gastrectomy BII anticolic anastomosis, D2 dissection, with T-colectomy and HIPEC on 20200810 , post-Op adjuvant CCRT. Consult for hyponatremia.
        • Lab data:
          • WBC: 2.76, Hb: 11.9,Plt: 182
          • Na: 132-> 128-> 126-> 125(8/9)-> 115(8/12)
          • K: 4.3, Ca: 2.42, Albumin: 4.6, Ca: 2.14, Mg: 1.7
          • BUN: 16, Cre: 0.75
          • Uric acid: 1.6, T bil: 1.03, D bil: 0.21, GOT :31
          • E4V5M6, BW 67.15kg
        • Assessment :
          • Severe acute hyponatremia
        • Suggetsion:
          • Supplementation with 3% NS run 20ml per hr for one day
          • Follow up serum Na Q4hr and not more than 8-10mmol/L per day
          • Check plasma osmolality, urine osmolarity and urine Na, FeNa, Fe uric acid (serum uric acid, urine uric acid, serum Cr, urine Cr) , TSH, Free T4, ACTH, cortisol
          • We will follow up this case.
        • Follow up (20220813)
          • Lab
            • Na: 117
            • Urine uric aicd : 21.7
            • Urine osmolarity: 377
            • Plasma osmolality : 236
            • Uric acid: 1.6
          • Assessment: suspect SIADH
          • Suggestion:
            • Keep 3% NS 20ml per hr for 2 days
            • Fluid restriction
            • Follow up Na Q4h or Q6h
            • Lasix 1 amp IV st
  • surgical operation
    • 2020-08-10
      • Surgery
        • Subtotal gastrectomy with D2 LNdissection
        • mesocolon resection
        • HIPEC with Oxaliplatinum 360mg/M2 650 mg T 42 C for 60 mins
        • B-II anticolic anastomosis
      • Finding
        • huge gastric ulcerative mass at greater cuvature with direct invasion to moesocolon
        • small nodular seeding at greater omentum
        • ascite(-)
  • chemoimmunotherapy
    • 2022-10-25 - irinotecan 160mg/m2 270mg 1.5hr + leucovorin 400mg/m2 670mg 1.5hr + fluorouracil 2800mg/m2 4700mg 46hr
    • 2022-08-22 - fluorouracil 200mg/m2 350mg 24hr D1-D3 (CCRT)
    • 2022-08-15 - fluorouracil 200mg/m2 350mg 24hr D1-D5 (CCRT)
    • 2022-08-09 - fluorouracil 200mg/m2 350mg 24hr D1-D4 (CCRT)
    • 2021-05-11 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
    • 2021-04-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
    • 2021-04-12 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-03-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-03-15 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-02-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-01-25 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2021-01-11 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2020-12-28 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2020-12-14 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • 2020-11-17 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • 2020-10-12 - fluorouracil 200mg/m2 350mg 24hr D1-D5 (CCRT)
    • 2020-10-01 - fluorouracil 200mg/m2 350mg 24hr D1 (CCRT)
    • 2020-09-28 - fluorouracil 200mg/m2 350mg 24hr D1-D3 (CCRT)
    • 2020-09-15 - fluorouracil 200mg/m2 350mg 24hr D1-D4 (CCRT)
    • 2020-08-10 - [cisplatin 360mg/m2 650mg + gentamicin 40mg + sodium bicarbonate 7% 60mL] IP 1hr for HIPEC at OR

[assessment]

  • As the patient reported bilateral lower limb edema after taking Lyrica (pregabalin), so the pregabalin has been held for the moment. As part of discharge preparations, gabapentin could be prescribed as a substitute for pregabalin for the patient’s neuropathic pain with less than half the risk of edema. (ref: UpToDate)

700900195

221114

  • exam findings
    • 2022-11-08 CT - brain
      • No ICH. Brain atrophy. Old left anterior basal ganglia lacunar infarcts.
    • 2022-08-22 MRI - c-spine
      • Cervical spondylosis, retrolordotic change, subluxation, mild spinal canal stenoses.
    • 2022-01-07 CT - c-spine
      • Cervical spinal kyphosis.
      • Degenerative spinal and disc disease.
      • Severe right C4-5, C5-6 neuroforaminal narrowing.
    • 2021-05-11 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 13) / 54 = 75.93%
        • M-mode (Teichholz) = 76
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild AR, TR
    • 2021-05-11 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.

[assessment]

  • Following the last cholesterol total measurement in April 2021 (275 mg/dL), there has been no further follow-up. It might be beneficial to collect the reading again to determine whether a statin agent is required (Zulitor (pitavastatin 4mg) 1# QN has been used in the past).

701447350

221114

  • exam findings
    • 2022-10-31 Pelvis & Bilat. Hip Lat
      • There is an osteolytic or osteopenic lesion in the lesser trochanter of right femur. Please correlate with CT to R/O bony metastasis.
    • 2022-10-05 Tc-99m MDP whole body bone scan
      • A hot area in the right iliac bone and increased activity in the sternum, malignancy with bone metastases should be considered, suggesting further investigation.
      • Increased activity in the sacrum, left humerus, and left hip, the nature is to be determined (bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for evaluation.
      • Suspected benign lesions in some C-, T- and L-spine, bilateral shoulders, and right femoral trochanter.
    • 2022-10-04 Patho - liver biopsy
      • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma
      • The sections show adenocarcinoma, poorly differentiated, composed of nests of large pleomorphic neoplastic cells, arranged in solid pattern with desmoplastic stromal reaction. Subtle glandular formation is present.
      • IHC, tumor cells reveal: CK7(+), CK20(-), Hepa-1(-) and Arginase-1(-).
    • 2022-09-14 CT - abdomen
      • Hepatocholangiocarcinoma is highly suspected. The differential diagnosis include cholangiocarcinoma and metastases? Biopsy is indicated.
      • Multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space.
      • Bony metastases.
  • consultation
    • 2022-11-02 Radiation Oncology
      • A
        • A: Intrahepatic cholangiocarcinoma with multiple metastases.
        • P: Radiotherapy is indicated for this patient with the following indicators: bone metastases.
          • Goal: palliation
          • Treatment target and volume: metastatic right ilium, sacrum, and right lesser trochanter lesions
          • Technique: IMRT
          • Preliminary planning dose: 3000cGy/12 fractions of the metastatic right ilium, sacrum, and right lesser trochanter lesions.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2022-11-07.
    • 2022-10-28 Rheumatology
      • Q
        • This 64-year-old man, a patient of being diagnosed to have HBV-related HCC several years ago (3-4 yrs) post TAE at SYKCC & bililary ca was diagnosed later and received further chemotherapy (cisplatin and gemza x 7 times) and bone met S/P R/T x 6 times was noted later. He was admitted for C/T. He complained of whole body skin rash & icthing did not improve for days. The ANA:1:80, IgE: 425. We need expertise to evaluate his condition thanks!
      • A
        • History review was performed. Patient was admitted due to HBV-related HCC & for C/T. I was consulted for generalized itching sensation.
        • RIA condition:
          • Allergic rhinitis Hx(+)
          • multiple small papules over four limbs
          • WBC/Hgb/PLT:4550/8.1/49K; Eosinophils:1.1%
          • IgE:425
          • ANA:1:80(s)
        • Suggestion:
          • Treatment as current your expert’s management.
          • Please check cryoglobulin, Panel 5 specific allergen test.
          • Keep allegra 1#BID & add chlorpheniramine 1# prn HS.
    • 2022-10-03 Dermatology
      • Q
        • for skin rash & icthing over whole body
        • This 64-year-old man, Being diagnosed to have HBV-related HCC several years ago (3-4 yrs) post TAE at SYKCC . Bililary ca was diagnosed later and received further chemotherapy (cisplatin and gemza )and bone met was noted later. The abdominal CT (9/14 22) showed Hepatocholangiocarcinoma is highly suspected. The differential diagnosis include cholangiocarcinoma and metastases? Biopsy is indicated.Multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space,Bony metastases. He complained of skin rash & icthing over whole body for days. We need expertise to evaluate his condition thanks!
      • A
        • This patient suffered from erythematous papules on limbs for 2 wks. and dyskeratoticnails for yrs.
        • Imp:
          • Subacute dermatitis
          • Tinea unguim
        • Suggestion:
          • Please check CBC. ANA. TSH. IgE
          • Dexamethason * 1 /Qd
          • Topsym cream * 4 tubes/bid
          • Excelderm soln * 2 Bt/Bid
  • chemoimmunotherapy
    • 2022-10-31 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5300mg 46hr

700132355

221110

[assessment]

  • The trough value of vancomycin was reported on 2022-11-10 at 25.4 mcg/mL.

  • A blood draw time of “2022-11-10 00:00” has been recorded, this should be due to an invalid entry, please confirm that the concentration is actually a “trough”.

  • Redraw the value if it is not truly a “trough”.

  • In the event that the value is a real “trough”, then it is recommended to hold vancomycin and perform a renal function test.

700161803

221103

  • exam findings
    • 2022-11-02 CT - abdomen
      • Findings:
        • There are multiple enlarged lymph nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, mesentery, para-aortic space, para-cava space, and bilateral common iliac chain.
          • Metastatic nodes are highly suspected.
          • The differential diagnosis include lymphoma.
          • In addition, thrombosis in right superficial femoral vein is noted.
        • There is diffuse wall thickening at the low body and antrum of the stomach. Please correlate with gastroscopy.
        • Prior CT identified a poor enhancing Soft tissue tumor, 4cm in the uterus, is noted again, stationary. Myoma is suspected.
          • In addition, There is a homogeneous soft tissue mass measuring 2.8 x 1.8 cm in left adnexa, near the uterine fundus, that also may be myoma.
        • Bilateral renal cysts, up to 2.6cm.
        • There are massive bilateral Pleura effusion.
      • Impression:
        • Multiple Metastatic nodes are highly suspected.
          • The differential diagnosis include lymphoma.
          • In addition, thrombosis in Rt superficial femoral vein is noted.
    • 2021-05-15 CT - abdomen
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
    • 2021-05-11 Patho - stomach biopsy
      • Stomach, GC-PW of middle body, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show a picture of tubular adenocarcinoma, moderately differentiated, composed of gastric mucosal tissue with columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic reaction.

[assessment]

  • Low molecular weight heparin (LMWH) is probably superior to unfractionated heparin (UFH) in reducing mortality in the initial treatment of venous thromboembolism (VTE) in people with cancer (2022-11-02 CT: thrombosis in right superficial femoral vein). Also, there are additional advantages of LMWH related to subcutaneous administration and outpatient management. (ref: Anticoagulation for the initial treatment of venous thromboembolism in people with cancer. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD006649. DOI: 10.1002/14651858.CD006649.pub8). For most patients with active malignancy and acute VTE who have a reasonable life expectancy and adequate renal function (CrCl >=30 mL/minute), LMWH is the preferred agent for initial anticoagulation, rather than other agents.

701035130

221103

  • diagnosis - 2022-11-02 adminssion note
    • Unspecified abdominal pain
    • Malignant neoplasm of unspecified part of left bronchus or lung
    • Malignant neoplasm of esophagus, unspecified
    • Chronic viral hepatitis C
    • Malignant neoplasm of upper lobe, left bronchus or lung
    • Malignant neoplasm of middle third of esophagus
    • Alcohol dependence, uncomplicated
    • Secondary malignant neoplasm of bone
    • Calculus of bile duct with cholangitis, unspecified, with obstruction
  • exam findings
    • 2022-10-06 Tc-99m MDP whole body bone scan with SPECT
      • The scintigraphic findings suggest multiple bone metastases.
      • Increased activity around right hip prosthesis. The nature is to be determined (infection or inflammation? other nature?). Please correlate with other clinical findings.
      • Mildly increased activity in the right knee. Arthritis may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 2022-10-05 Patho - pleural/pericardial biopsy
      • Lung, left upper lobe, CT-guide biopsy — small cell carcinoma
      • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and marked crushing artifact.
      • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(-), Napsin A(-), Synaptophysin(-), Chromogranin A(-), CK5/6(-), p40(-), GATA3(focal +), SALL4(-), OCT4(-), and beta-hCG(-). The morphology is the same as S2022-16555.
    • 2022-09-30 MRI - pancreas
      • History: 20220924 CC: abdomen pain
        • 20220924 CT: A mass (2.6x5.4cm) at LUL and left pulmonary hilum. Some LNs at mediastinum, hepatic hilum, and retroperitoneum. Some hypodense lesions (up to 4.7cm) in both hepatic lobes.
          • Suspected lung cancer at LUL with LNs and liver metastases
        • 20220927 CA199: 19090 U/mL (< 35), CEA and AFP: normal.
        • 20220928 liver biopsy: neuroendocrine carcinoma
    • 2022-09-28 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Poorly differentiated carcinoma,compatible with neuroendocrine carcinoma
      • The sections show nests of medium to large-sized, poorly differentiated neoplastic cells with marked apoptosis, in fibrous stroma. Neither squamous nor glandular differentiation can be identified.
      • IHC shows: CK(+), p40(-), TTF1(-), CD56 (+), and Synaptophysin(-). The findings favor neuroendocrine carcinoma.
    • 2022-09-28 Patho - stomach biopsy (middle esophagus)
      • Labeled as “middle esophagus”, biopsy (B) — squamous cell carcinoma.
      • IHC stains: CK5/6 (+), p63 (+).
    • 2022-09-26 SONO - abdomen
      • Diagnosis
        • Liver tumors, favor metastatic tumors
        • liver parenchymal disease
        • mild GB wall thickening
      • Suggestion
        • correlate with other image study such as contrast-enhanced CT scan or MRI
    • 2022-09-24 CT - chest
      • Suspected lung cancer at LUL with LNs and liver metastases. Suggest tissue study.
  • consultation
    • 2022-11-02 Family Medicine
      • Q
        • This is a 51-year-old man with past history of
          • Squamous cell carcinoma involved middle esopahgus
          • Nueroendocrine carcinoma of liver, poor differentiated, multiple metastatic lymph nodes
          • Small cell carcinoma of lung
          • Tc99m: multiple bone metastasis
          • Left hip AVN, alcoholism related, s/p left THR in 2013 at WanFang Hospital.
          • Left distal tibial fracture and lateral malleolar fracture by trauma, s/p ORIF with plate fixation in 2017/07
          • Left THR acetabular component loosening, s/p left hip revision THR in 2017/12
          • Right hip s/p bipolar hemiarthoplasty s/p infection, s/p ROI and antibiotic cement beads insertion in 2020/04
          • Hepatitis C under Maviret treatment since 20221021.
        • According to family, the patient developed chest tightness, abdominal pain, and severe right knee pain for several days. Productive cough with difficult swallowing were also noted. So he visited our ER for help. He managed to talk oriently and was able to eat by himself then.
          • Vital sign at ER revealed BP:117/76 mmHg; HR:102 bpm; BT:35.6 celsius degree; RR:18 /min ; GCS:E4V5M6. Laboratory data revealed leukocytosis, elevated CRP and direct/total bilirubin. Icteric appearance was noted. Cefataxime was prescribed at ER. However, he became lethargy and confused this morning. Though his eyes opened spontaneously, he could not answer questions properly or obey order. Productive cough was also noted. Under the impression of (1) squamous cell carcinoma involved middle esopahgus (2) Nueroendocrine carcinoma of liver (3) Small cell carcinoma of lungs (4) altered mental status (5) pneumonia, the patient was admitted for further evaluation and management. Due to difficult swallowing and altermental status, NG tube was inserted today.
        • Considering the irreversible end stage cancers and his family decided not to accept advanced treatment, we need your expertise for this patient’s hospice care. Thank you very much!!
      • A
        • After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
        • Current condition: 51 y/o Esophageal cancer, bone mets
        • Indication for hospice combine care: Advanced esophageal cancer
    • 2022-10-03 Hemato-Oncology
      • Q
        • This is a 51-year-old man, who was admitted for GI bleeding. PES was done and his vital signs is stable now. Further investigation revealed 1. Esophageal Ca, r/o lung cancer and liver neuroendocrine carcnioma were noted.
        • We would like to request your expertise upon further management of the condition.
      • A
        • This 51-year-old man was consulted and evaluated for liver tumor and esophageal cancer.
        • History and medical records reviewed and patient interviewed at bedside.
        • Recommendation:
          • lung biopsy to R/O small cell carcinoma of lung
          • chemotherpay with cisplatin based regimen is suggested after the lung tumor pathology is elucidated.
          • check bone scan
          • suggest to consult the radiation oncologist for possible of CCRT
        • I will follow up this patient, Thank you for the referral.
    • 2022-09-27 Thoracic Medicine
      • Q
        • This is a 51-year-old patient, he came to our ward since GI bleeding.
        • On 20220924, chest x ray shows: Mass like lesion at left upper lobe is found.
        • on 20220924, CT shows: A mass (2.6x5.4cm) at LUL abutting mediastinum and left pulmonary hilum.
        • Meanwhile, abdominal sonography shows multiple liver tumors, metastatic suspected.
        • We would like to consult to Dr. we wonder if there’s any advices, or would you recommand surgical intervention for the patient?
        • Please insight us. Thanks for your time and reply.
      • A
        • This 51-year-old man without chronic disease was admitted due to GI bleeding and CXR showed incidental finding of lung tumor.
          • Chest CT revealed multiple liver hypodense tumor with LUL mass near hilum with multiple LD at retroperitonium, and mediastinum. Therefore, we were consulted for further evaalution and management.
        • Lab:
          • CA19-9: 19090, AFP, CEA: normal
          • Anti-HCV: (+)
          • smoking, alcohol, and betel nut history: (+)
          • Panendoscopy revealed esophageal lesion post biopsy, GU post biopsy, and DU scar.
        • Impression:
          • Lung tumor with multiple liver tumor and LN with esophageal lesion, primary origin?
          • Gastric ulcer, with esophageal lesion s/p biopsy
        • Suggestion:
          • Pending biopsy report
          • Could ask the interventional radiologist for CT guided biopsy (liver tumor first due to lower risk) if negative findings of esophageal lesion.
            • If interventional radiologist refuse, we could arrange bronchoscopy to see whether we could approach the mass lesion.
          • could also check other tumor marker - SCC for evaluation.
          • Treat Gi bleeding as your expertise.
          • We will closely follow up the patient.
        • Thanks for your consultation
    • 2022-09-26 Rehabiliation
      • A
        • Right knee:
          • No erythermatous change, no swelling, no heating, no tenderness over his right knee
          • Lockman test: negative; McMurray test: Positive
          • Pain when flexion and extension ROM, relief after resting
        • Right knee sonogram: mild effusion in suprapatellar
        • Assessment
          • Right knee internal derangement
        • Plan
          • Arranged right knee sonogram (done, pending report)
          • Knee IA with low dose steriod injection
          • Please arrange right knee X-ray, and MRI
          • Please arrange rehab OPD after discharge for follow up if his right knee is still pain

[assessment]

  • Tube feeding is possible for all oral medications in the active prescription.
  • It is recommended that the patient-carried medication Maviret (glecaprevir 100mg + pibrentasvir 40mg) be taken with food (cum cibos) and the frequency should be amended to QDCC.

701458197

221031

{drug identification}

requesting drug identification for 1 item.

the item is identified as Serenal (oxazolam 10mg/cap).

the drug will be sent back to ward by an in-hospital porter.

701272100

221028

  • diagnosis 2022-06-24 discharge
    • Pancreas adenocarcinoma, pT2N2(cM0); Stage III status post pylorus-preserving pancreaticoduodenectomy with lymph node dissection on 2021/03/29 s/p concurrent chemoradiotherapy
    • Chronic viral hepatitis B without delta-agent
  • exam finding
    • 2022-09-09 CT - abdomen
      • FINDINGS:
        • Prior CT identified several metastatic nodes in para-aortic space and left common iliac chain are noted again, decreasing in size that may be metastatic nodes S/P C/T with partial response .
        • S/P Whipple operation and S/P cholecystectomy.
          • Mild dilatation of the IHDs on both lobes are noted.
          • Please correlate with serum alk-p and bilirubin level.
        • There is a poor enhancing lesion 1.1 cm in S6 liver that is c/w cyst.
        • There is a enlarged node measuring 1.8 x 1.1 cm in the para-tracheal space that may be metastatic node.
      • IMP:
        • Metastatic nodes in para-aortic space and left common iliac chain S/P C/T show partial response. Follow up is indicated.
        • Metastatic node in paratracheal space measuring 1.8 x 1.1 cm is highly suspected.
    • 2022-07-15 Tc-99m MDP whole body bone scan
      • Mildly increased activity in the lower C- and lower L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
    • 2022-06-21 SONO - neurology
      • Minimal atherosclerosis in bilateral CCA bifurcations.
      • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows.
    • 2022-06-16 MRI - brain
      • No abnormal enhancing lesion within brain parenchyma.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • 2022-05-25 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-05-25 CT - abdomen, pelvis
      • Findings:
        • There are several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
        • S/P Whipple operation and S/P cholecystectomy.
        • Mild pneumobilia on both lobes IHDs are noted.
        • There is a poor enhancing lesion 1.1 cm in S6 liver that is c/w cyst.
      • Imp:
        • There are several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
    • 2022-03-28 Patho - soft tissue biopsy/simple excision (non lipoma)
      • Skin and soft tissue, abdominal wall #1, excision — Fat necrosis
      • Soft tissue, abdominal wall #2, excision — Fat necrosis
    • 2022-03-01 Patho - soft tissue debridment
      • Labeled as “abdominal wall tumor around the scar region”, clinical history of pancreatic ductal carcinoma, needle biopsy — fibrosis.
      • IHC stains: CD68 highlights many histiocytes. CK (-): no carcinoma.
    • 2022-02-25 CT - abdomen, pelvis
      • S/P Whipple operation and S/P cholecystectomy. There is no evidence of tumor recurrence.
      • Mild pneumobilia on both lobes IHDs are noted.
    • 2021-10-14 CT - abdomen, pelvis
      • Pancreatic cancer s/p operation. No evidence of tumor recurrence.
    • 2021-07-27 MRI - MR Cholangiography, MRCP
      • Pancreatic cancer s/p operation. No evidence of tumor recurrence.
    • 2021-07-07 CT - abdomen, pelvis
      • Findings
        • S/P Whipple operation and S/P cholecystectomy.
        • There is mild fatty stranding and suspicious mild fluid collection at the anastomosis area of the pancreaticojejunostomy that may be post-operative change. The differential diagnosis include partial leakage? please correlate with clinical condition.
        • There is a round, encapsulated lesion in the subcutaneous fat layer of the midline incisional wound with a central area of predominantly fat attenuation, a finding indicative of encapsulated fat necrosis.
        • Mild ascites in the pelvis is suspected.
        • Fatty liver, grade 4, is noted.
      • IMP:
        • Post-operative change at the anastomosis area of the pancreaticojejunostomy is suspected. The differential diagnosis include partial leakage? please correlate with clinical condition.
        • Encapsulated Fat necrosis in the subcutaneous fat layer of the incisional wound is suspected.
    • 2021-03-30 Patho - gallbladder (benign lesion)
      • Gallbladder, cholecystectomy — Chronic cholecystitis
      • The sections show a picture of chronic cholecystitis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
    • 2021-03-30 Patho - liver partial resection
      • pathologic diagnosis
        • Lymph nodes, LN 7, 8, 9, 11p, 12, dissection — Metastatic adenocarcinoma (1/18)
        • Lymph node, J1, dissection — Metastatic adenocarcinoma (1/1)
        • Lymph node, SMV, dissection — Metastatic adenocarcinoma (1/1)
    • 2021-03-30 Patho - pancreas total/subtotal resection
      • pathologic diagnosis
        • Pancreas, Whipple operation — Ductal adenocarcinoma, moderately differentiated
        • Lymph nodes, regional, Whipple operation — Metastatic carcinoma (8/44)
        • Pathologic Staging: pT2N2; Stage III if cM0
      • macroscopic examination
        • Specimen Type: Whipple operation
        • Venous (Large Vessel) Invasion: Absent
      • microscopic examination Representative parts are taken for section and labeled as: A1=
        • Histologic Type: Ductal adenocarcinoma
        • Histologic Grade: Moderately differentiated (G2)
        • Tumor Extension: Tumor invades peripancreatic soft tissue
        • Lymphvascular Invasion: Present
    • 2021-03-12 Patho - pancreas biopsy
      • Labeled as “pancreatic tumor”, EUS guided FNA/B of Pancreas — adenocarcinoma.
      • IHC stain: CK highlights small irregular infiltrative neoplastic ducts.
      • Section shows cores of markedly necrotic tissue with atypical mucinous gnads.
    • 2021-03-12 Cell block
      • cytologic diagnosis
        • Atypia
      • gross description
        • 32 cc, light orange, turbid
      • microscopic description
        • Smears an cell block show scant atypical hyperchromatic epithelial cells. The speicmen may not be representative for low cellularity.
    • 2021-03-12 Endoscopic Ultrasonography, EUS
      • Diagnosis
        • Suspected Pancreatic head cancer s/p CH-EUS & EUS/FNB
        • Pancreatic cystic lesions, pancreatic body, suspected IPMN
        • Peri-pancreatic lymphadenopathy
        • Shallow duodenal ulcer, bulb
      • Suggestion
        • F/u pathology
        • PPI use for ulcer
    • 2021-03-11 Abdominal Ultrasonography
      • Diagnosis
        • Pancreatic tumor, uncinate process
        • Pancreatic cystic lesions, body
        • Main pancreatic duct dilatation
        • Liver cysts, three, S3 and S6
        • Suspected renal stone, left kidney
      • Suggestion
        • correlated wtih other images and tumor markers
  • consultation
    • 2022-06-15 ENT
      • Q
        • For dizziness when turn the neck for 1 week.
        • This 64-year-old female has past history of gastric ulcer. According for her statement, she noted for pancreatic tumor for 3 years with regular follow up at other hospital. However, health examination revealed pancreatic lesion by abdomen MRI which showed a 2.2cm sized progressive rim enhancing lesion is noted at uncinate process of the pancreas, with high signal intensity on T2WI, diffusion restriction, nature to be determined. suspect of pancreatic cancer, solid pseudopapillary tumor. She came to our OPD for further management. EUS was also performed and showed 1) R/o Pancreatic head cancer s/p biopsy. 2) Pancreatic cystic lesions, pancreatic body, r/o IPMN. 3) Peri-pancreatic lymphadenopathy. 4) Shallow duodenal ulcer, bulb. Tumor marker of CEA: 2.05ng/ml, CA-199: 469.32U/ml on 2021/03/16. She referred to our GS OPD for further treatment.
        • Now, she is admitted for Abraxane and Gemcitabine on 2022-06-14, she complaints dizziness when turn the neck for 1 week, so we need tour help, thanks a lot!!
      • A
        • PE: Bil. Dix-Hallpike test negative, no spontaneous nor motional nystagmus
        • According to her statement, favoring resolved BPPV, unspecific ear
        • However, still have to r/o tumor metastasis
        • May prescribe Diphenidol for her remaining dizziness
    • 2021-08-20 Infectious Disease
      • Q
        • This 63-year-old is a case of Pancreas adenocarcinoma, pT2N2(cM0); Stage III status post pylorus-preserving pancreaticoduodenectomy with LN dissection s/p CCRT. This time, for abdominal wound casr with pus in 2021/07 with antibiotic Metrozole 1# po QID and Amoxicillin 2# po Q8H theraoy. But, Pus/C showed normal. Now, for evaluate antibiotic therapy. Thank you.
      • A
        • A 63-year-old woman of pancreas adenocarcinoma. Wound/pus culture revealed no growth. The common infecting bacteria of deep wound infection including Streptococci, Staphylococci, and gram negative-negative enteric bacteria possible. MRSA has been reported to account for up to 21% of nosocomial skin infections. Vancomycin typically is the drug of choice for methicillin-resistant coagulase-negative and coagulase-positive staphylococcal infections. It is also useful against penicillin-resistant streptococcal infections. Anti-microbiologic coverage as with parenteral Vancocin 500 mg or + - (plus Fortum 1.0 gm) q12h is recommended.
    • 2021-04-10 Hemato-Oncology
      • Q
        • For further chemotherapy
        • This 64 y/o female a case of pancreatic head cancer s/p PPPD + LND on 20220329. The final pathology revealed ductal adenocarcinoma, moderately differentiated, lymph nodes metastatic (8/44), Staging: pT2N2M0; Stage III. Now, her condition improve and appetite fair. We need your expertise for further chemotherapy. Thanks for your times.
      • A
        • A case MD pancreatic ductal adenocarinoma, post PPPD and LND, pT2N2(8/44)M0, Stage III, was noted.
        • My suggestion would be:
          • The adjuvnat treatment is mandatory. May consider CCRT followed by C/T
          • Please check HBV (HBs Ag, Anti-HBs Ab, Anti-HBc Ab) and HCV (Anti-HCV) status during this admission, or I will check in my OPD
          • If possible, please check CA199/CEA, or I will check in my OPD
          • If MBD, please arrange my OPD
          • Please arrange Port-A if possible.
        • Thanks for your consultation. Any problem, please let me know.
    • 2021-04-09 Radiation Oncology
      • Q
        • For further radiotherapy
        • This 64 y/o female a case of pancreatic head cancer s/p PPPD + LND on 20220329. The final pathology revealed ductal adenocarcinoma, moderately differentiated, lymph nodes metastatic (8/44), Staging: pT2N2M0; Stage III. We need your expertise for further radiotherapy. Thanks for your times.
      • A
        • The patient’s history was reviewed and patient was examined.
        • S:
          • For postoperative radiotherapy due to pancreatic cancer.
          • PI: Ductal adenocarcinoma, moderately differentiated of the pancreas, pathologic Staging: pT2N2(cM0); Stage III, s/p PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection on 2021-03-29.
          • Family history: (father: prostate cancer, elder brother: esophageal cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Other disease: (-)
          • Previous RT Hx: (-)
        • O:
          • ECOG: 1
          • PE: neck and bil SCF: neg; abdomen: surgical scar and status during drainage.
          • CXR (2021-03-09): Essential negative findings
          • Abd sono (2021-03-11): pancreatic tumor, uncinated process; pancreatic cystic lesions, body; main pancreatic duct dilatation; liver cysts, three, S3 and S6; suspected renal stone, left kidney.
          • CA199 (2021-03-16): 469.32
          • Operation (2021-03-29): PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection.
          • Pathology (S2021-04713, 2021-04-01): 1. Lymph nodes, LN 7, 8, 9, 11p, 12, dissection — Metastatic adenocarcinoma (1/18). 2. Lymph node, J1, dissection — Metastatic adenocarcinoma (1/1). 3. Lymph node, SMV, dissection — Metastatic adenocarcinoma (1/1).
          • Pathology (S2021-04715, 2021-04-01): 1. Pancreas, Whipple operation — Ductal adenocarcinoma, moderately differentiated. 2. Lymph nodes, regional, Whipple operation — Metastatic carcinoma (8/44). 3. Pathologic Staging: pT2N2; Stage III if cM0. Uncinate margin: Uninvolved by invasive carcinoma, 1 mm from closest margin.
        • A:
          • Ductal adenocarcinoma, moderately differentiated of the pancreas, pathologic Staging: pT2N2(cM0); Stage III, s/p PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection.
        • P:
          • Radiotherapy is indicated for this patient with the following indicators: Staging: pT2N2(cM0); Stage III, and close margin.
          • Goal: curative
          • Treatment target and volume: pancreatic tumor bed, peripheral, to regional lymphatic area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 4500cGy/25 fractiobns
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her brother’s son. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-04-22.
  • surgical operation
    • 2021-03-29
      • Surgery
        • PPPD with LN 5, 6, 7, 8, 9, 11p, 12, 14a & v dissection
      • Finding
        • 2 x 2.0cm tumor at uncinate process with SMV partial invasion
        • multiple LN palpable at proximal SMA to J1
        • P-duct 3mm with soft pancreas
        • C-duct 1.0cm
    • 2021-03-28
      • Surgery
        • Excision of subcut tumor 4 x 2 cm
        • and 1.5 x 1.0 cm at midline abdominal wound
      • Finding
        • two subcut hard mass at upper mdiline laparotomy wound
        • 4 cm and 1.5 cm
  • radiotherapy
    • 2021-04-29 ~ 2021-06-02) - 4500cGy/25 fractions (15MV photon) of the pancreatic tumor bed, peripheral, to regional lymphatic area.
  • chemoimmunotherapy
    • 2022-10-19 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-10-05 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-09-28 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-09-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-09-07 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-08-24 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-08-17 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-08-03 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-07-20 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-07-13 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-06-29 - gemcitabine 1000mg/m2 1400mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-06-23 - gemcitabine 1000mg/m2 1400mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-02-09 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2022-01-18 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2022-01-03 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-12-16 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-12-01 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-11-16 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-11-03 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-10-15 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-09-30 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-09-09 - gemcitabine 1000mg/m2 1600mg 30min + oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 600mg 48hr + fluorouracil 2800mg/m2 4300mg 48hr
    • 2021-08-24 - gemcitabine 800mg/m2 1100mg 30min + oxaliplatin 65mg/m2 100mg 2hr + leucovorin 200mg/m2 280mg 48hr + fluorouracil 2000mg/m2 2800mg 48hr
    • 2021-07-19 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 65mg/m2 100mg 2hr + leucovorin 240mg/m2 350mg 48hr + fluorouracil 2400mg/m2 3500mg 48hr
    • 2021-06-02 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-05-27 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-05-17 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-05-07 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-04-29 - gemcitabine 400mg/m2 700mg 30min (CCRT)

[note]

  • NCCN Pancreatic Adenocarcinoma 20210225 evidence blocks p35~36
    • neoadjuvant therapy
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
      • Only for known BRCA1/2 or PALB2 mutations
        • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
        • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
    • adjuvant therapy
      • preferred regimens
        • Modified FOLFIRINOX (category 1)
        • Gemcitabine + capecitabine (category 1)
      • other recommended regimens
        • Gemcitabine (category 1)
        • 5-FU + leucovorin (category 1)
        • Continuous infusion 5-FU
        • Capecitabine (category 2B)
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU

==========

2022-10-28

  • According to 2022-09-09 CT (compared to 2022-05-25 CT), the disease has had a partial response to the current regimen started 2022-06-23.
  • Oxacillin (currently used) or cefalotin remain the drugs of choice for treating uncomplicated cellulitis (of left lower limb) in regions where community-acquired methicillin-resistant S. aureus is infrequent.
  • The active prescription does not pose any problems.

2022-06-15

  • 2022-05-25 CT showed several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
  • CA199 levels time series showed the biomarker has roughly tripled in the last six months.
    • 2022-06-13 88.35 U/mL
    • 2022-05-25 78.08 U/mL
    • 2022-04-29 83.18 U/mL
    • 2022-02-23 31.33 U/mL
    • 2022-01-26 28.59 U/mL
    • 2022-01-18 29.57 U/mL

701457957

221027

{colon cancer}

  • exam findings
    • 2022-10-22 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • Increased infiltration over RLL. May be active infection.

[assessment]

  • Fasting blood sugar level is highly volatile (103 ~ 419 mg/dL). Acute infections lead to difficulty in controlling blood sugar levels and infectious diseases are more frequent and/or serious in patients with diabetes mellitus. The patient has been prescribed biosynthetic human insulin.
  • Despite improvements in renal function compared to 2022-10-24, creatinine and BUN levels remain high (creatinine 2.33 mg/dL and BUN 55 mg/dL on 2022-10-27).
  • When there is no evidence of active bleeding, the pantoprazole injection might be switched to an oral PPI.

700014137

221026

{Extranodal NK/T-cell lymphoma, nasal type, Lugano stage II, PS: 0}

  • initial presentation
    • 2022-04
      • nasal stuffness and abscess discharge.
      • fever and weight loss about 4kg in 2 months and night sweats were also noted.
  • lab data
    • 2022-08-08 CMV viral load assay 39 IU/mL
    • Anti-HBc
      • 2022-06-09 Reactive 7.68 S/CO
    • EBV DNA PCR
      • 2022-06-08 2724 copies/mL
    • HBsAg
      • 2022-06-01 Negative 0.517
    • Anti-HCV
      • 2022-06-01 Negative 0.0409
  • exam finding
    • 2022-10-06 Sinoscopy
      • bil profuse otorrhea, L mucopus
    • 2022-09-19 Sinoscopy
      • nasal ca s/p CCRT
    • 2022-09-05 Nasopharyngoscopy
      • nasal cancer s/p CCRT
      • gr4 mucositis + mucopus
    • 2022-08-22 Sinoscopy
      • bil nasal synehiae (basal) + L IT synechiae lyzed after intranasal injection + L nasal packing + post nasal septal R/T mucositis, gr 3
      • post R/T mucositis, ENT local treatment done
    • 2022-08-22 Pure Tone Audiometry, PTA
      • Tymp:
        • Bil grommet
      • PTA
        • Reliability FAIR
        • Average RE 50 dB HL; LE 56 dB HL.
        • bil mild to severe mixed type HL.
        • tinnitus(+)
    • 2022-08-19 C-spine AP + Lat.
      • Degeneration and spondylosis of C-spine.
    • 2022-08-15 Nasopharyngoscopy
      • nasal ca under CCRT
    • 2022-08-02 Nasopharyngoscopy
      • crust and bloody discharge at bil nasal internal nasal valve and bil nasal septum, covered with Surgicel, smooth OPx, HPx
    • 2022-07-31 ECG
      • Sinus tachycardia
      • Left axis deviation
      • Abnormal ECG
    • 2022-07-28 Pure Tone Audiometry, PTA
      • Tymp:
        • R’t type C; L’t type B.
      • ART:
        • Bil absent.
      • PTA
        • Reliability FAIR
        • Average RE 61 dB HL; LE 54 dB HL.
        • R’t mild to profound MHL.
        • L’t moderate to severe mixed type HL.
    • 2022-07-21 Sinoscopy
      • much mucopus
      • no visible tumor
    • 2022-07-14 Nasopharyngoscopy
      • sinonasal lymphoma undergong CCRT
    • 2022-06-16 Sinoscopy
      • remove packing + R packing with Surgicel
      • 2022/6/13 fiber = R nasal cancer, bleeing spontaneous (cancer+) again after removal of nasal packing; thus, bil Merocel packing again
      • intermittent L epistaxis noted for 2 months, went to ShuangHo Hospital and Biopsy, NK/T-cell lymphoma, nasal type was diagnosed
      • went to our hospital for CCRT
      • Left epistaxis during admission, ENT was consulted, s/p L merocel packing
    • 2022-06-16 SONO - abdomen
      • Diagnosis
        • Fatty liver, moderate
        • Pancreas not shown
        • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
      • Suggestion
        • OPD f/u
        • Follow liver function test and AFP
        • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
        • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months.
    • 2022-06-15 Nerve Conduction Velocity (NCV), Electromyography (EMG)
      • Findings
        • The ENoG study showed a facial CMAP amplitude ratio as 73% (right/left) and prolonged distal latency in bilateral facial nerves.
        • The results of blink reflex study were within normal limits.
      • Conclusion
        • The above findings may suggest bilateral peripheral facial nerve lesion, more severe in the right side, with demyelinating pattern. Advise clinical correlation.
    • 2022-06-13 Nasopharyngoscopy
      • smooth NPx, OPx, HPx
    • 2022-06-01 CT - lung/mediastinum/pleura
      • no abnormality in the chest and upper abdomen.
    • 2022-05-30 MRI - larynx
      • Findings
        • Extensive soft tissue tumor with T1-hypointensity, T2-hyperintensity and vivid enhancement involving nasopharynx, soft palate, bilateral nasal cavities, bilateral ethmoid and sphenoid sinsues, right maxillary sinus wall, clivus and adjacent sphenoid bones.
        • No enlarged lymph node.
        • No abnormality at hypopharynx and larynx.
        • Diffuse mottled T2-hyperintensity filling in bilateral mastoid air cells, indicating amstoiditis.
        • No abnormality at parotid, submandibular and sublingual glands.
      • IMP:
        • Nasal-nasopharyngeal tumor with aforementioned involvement. D/D: lymphoma, NPC.
    • 2022-05-30 2D transthoracic echocardiography
      • Normal AV/MV with no AR/MR
      • Mild concentric LVH, normal LV wall motion
      • Preserved LV and RV systolic function
      • No PR, trivial TR, normal IVC size
    • 2022-05-30 EKG
      • Left axis deviation
    • 2022-05-28 CXR
      • Chest PA and Lat. LT view: Widening of the right upper mediastinum is suspected. Please correlate with CT.
    • 2022-05-17 PET scan (at ShuangHo Hospital)
      • c/w lymphoma involving a NP, nasal cavity, ethmoid sinus, soft palate.
    • 2022-05-03 Surgical pathology - nasal tumor biopsy (at ShuangHo Hospital)
      • extranodal NK/T-cell lymphoma, nasal type.
    • 2018-02-21 Blink Reflex Studies
      • The ENoG study showed facial CMAP amplitude ratio as 74 % (right/left). The blinking reflex study showed relatively prolonged ipsilateral R1 and R2 latency when right side stimulation and relatively prolonged contralateral R2 latency when left side stimulation. These findings may suggest right facial nerve lesion.
  • radiotherapy
    • 2022-06-22 ~ 2022-08-08 - 2000cGy/10 fractions of the nasal - nasopharyngeal, peripheral involved to bilateral neck nodal, and 5000cGy/25 fractions of the reduced nasal - nasopharyngeal, peripheral involved area.
  • chemoimmunotherapy
    • 2022-09-20 - carboplatin AUC 4 200mg/m2 300mg 2hr D1 + etoposide 67mg/m2 110mg 1hr D1-3 + ifosfamide 1000mg/m2 1700mg 4hr D1-3
    • 2022-08-29 - carboplatin AUC 2 150mg/m2 260mg 2hr D1 + etoposide 67mg/m2 110mg 1hr D1-3 + ifosfamide 900mg/m2 1500mg 4hr D1-3 (full dose: carboplatin 200mg/m2, etoposide 67mg/m2, ifosfamide 1000mg/m2)
    • 2022-07-21 - carboplatin AUC 2 150mg/m2 270mg 2hr D1 + etoposide 67mg/m2 120mg 2hr D1-3 + ifosfamide 900mg/m2 1600mg 4hr D1-3
    • 2022-06-08 - carboplatin AUC 2 150mg/m2 270mg 2hr D1 + etoposide 67mg/m2 120mg 2hr D1-3 + ifosfamide 900mg/m2 1600mg 4hr D1-3
  • G-CSF
    • 2022-09-06 Granocyte (lenograstim) 250mg QD SC OPD 2022-09-06
    • 2022-08-03 Granocyte (lenograstim) 250mg QD SC IPD 2022-07-31

==========

2022-10-26

  • Swelling around the eyes might be caused by inflammation resulting from a variety of conditions, including infection, injury, and allergies. If this is the case, some eye drops containing steroid/antihistamine and/or antimicrobial might be beneficial.

2022-08-30

  • Pure-tone audiometry 2022-08-22 RE 50 dB HL LE 56 dB HL <- 2022-07-28 RE 61 dB HL LE 54 dB HL. There is no evidence of rapid deterioration in hearing.
  • Tamsulosin has been prescribed. Please make sure that any possible obstruction to the urinary tract has been eliminated or corrected before beginning treatment with ifosfamide.

2022-07-22

  • 2022-06-15 electromyography suggested bilateral peripheral facial nerve lesion, more severe in the right side, with demyelinating pattern.
  • The neurology related adverse reaction incidences of the drugs in current regimen:
    • carboplatin - Nervous system: Neurotoxicity (5%), peripheral neuropathy (4% to 6%)
    • etoposide - Peripheral neuropathy (1% to 2%)
    • ifosfamide - Central nervous system: Brain disease (<=15%), central nervous system toxicity (<=15%)
  • Please monitor for newly developed neuropathy as usual.

2022-06-09

  • There is no re-biopsy performed at our facility, in addition to our imaging studies and pathology results from ShuangHo Hospital.
  • An EBV positive result (lab 2022-06-08 EBV DNA PCR 2724 copies/mL) is consistent with NK/T-cell, nasal type. EBV-associated T- and NK-cell lymphoproliferative disorders (LPD), including chronic active EBV infection (CAEBV), can progress to aggressive NK-cell leukemia (ANKL).
  • For extranodal NK/T-cell lymphomas, suggested treatment regimens can be (ref https://www.cancertherapyadvisor.com/wp-content/uploads/sites/12/2018/12/nhl-extranodalnk_0318_9414.pdf )
    • combination chemotherapy regimen (asparaginase-based)
      • Modified SMILE (steroid [dexamethasone], methotrexate, ifosfamide, pegaspargase, and etoposide) x 4-6 cycles for advanced stage
      • P-GEMOX (gemcitabine, pegaspargase, and oxaliplatin)
      • DDGP (dexamethasone, cisplatin, gemcitabine, pegaspargase)
    • combined modality therapy
      • concurrent chemoradiation therapy: RT and 3 courses of DeVIC (dexamethasone, etoposide, ifosfamide, and carboplatin) <= currently applied.
      • sequential chemoradiation: For stage I, II, modified SMILE x 2-4 cycles followed by RT
      • sandwich chemoradiation: P-GEMOX x 2 cycles followed by RT followed by P-GEMOX x 2-4 cycles
  • CCRT using DeVIC is currently being applied during this hospital stay.
  • Lab results 2022-06-08 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB is relatively stable.
  • There is a self-carried drug - amoxicillin 500mg PO Q8H - listed in active prescription for the apical infection of tooth 26 and its complicated extraction.

701049370

221025

  • diagnosis 20221003 discharge
    • B cell lymphoma, high grade, stage IV
    • Splenomegaly, not elsewhere classified
  • exam findings
    • 2022-09-30 CXR
      • Fibrosis of left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • 2022-09-19 Whole body PET scan
      • Glucose hypermetabolism lesions in bilateral cervical, bilateral axillary, celiac chain, bilateral para-aortic space, and pre-vertebral lymph nodes of lower T-spine, and spleen, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      • Glucose hypermetabolism lesions in T9-11 spines, highly suspected lymphoma with involvement of bones and/or bone marrow.
      • Increased FDG uptake in bilateral pulmonary hilar and bilateral mediastinal lymph nodes, probably reactive nodes (priority) or lymphoma with involvement of lymph node regions, suggesting further investigation.
      • B cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2022-09-20 CXR
      • Interstitial pattern at LUL.
    • 2022-09-15 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Atypical lymphoid aggregates, favor reactive
      • The sections show normocellular marrow (30%). The myeloid series show good maturation. The megakaryocytes are normal in number and morphology. Scattered interstitial, mixed small and large lymphoid cell aggregates are present.
      • IHC, a mixture of CD3+ T and CD20+ B lymphocytes haphazardly arranged with slightly B cell predominant are noted. The B cells also show: BCL6(focal +), CD10(-), and CD23(-). The findings favor reactive lymphoid aggregates. Suggest bone marrow smear evaluation and clinic correlation.
    • 2022-09-01 Patho - fibrolipoma
      • Labeled as “right neck”, excisional biopsy — B cell lymphoma, high grade.
      • Section shows lymph nodes with architecture obscured by large blasts like neoplastic lymphoid cells (more than 15/HPFs) and scattered centrocytes like cells.
      • IHC stains: CK (-), CD3 (focal+), CD20 (diffuse +), CD10 (+), bcl-2 (+), bcl-6 (+), MUM-1 (focal +, 10%), Ki-67: 60%, cyclin-D1: (equivocal), c-myc (-). Vague lymphoid follicles are highlighted by IHC stains. The pattern is suggestive of follicular lymphoma, grade 3A.
    • 2022-09-01 CT - abdomen
      • Thickening of right posterior pleura and prevertebral tissue at T10-12.
      • Portal hypertension and splenomegaly.
      • Some LNs (up to 2.0cm) at retroperitoneum.
    • 2022-03-24 CT - abdomen
      • Thickening of right posterior pleura and prevertebral tissue at T10-12.
      • Increased soft tissue at left pubic cavity.
      • Portal hypertension and splenomegaly.
    • 2021-12-21 Patho - soft tissue nontumor/mass/lipoma/degridement
      • Soft tissue mass, left pelvic cavity, CT-guide biopsy — Suggestive of benign, reactive change
      • Microscopically, the sections show a picture of almost small to medium-sized lymphocytes infiltration with monocytoid feature.
      • Immunohistochemistry shows CK(-), CD3, CD5 and CD43 (+, diffuse), CD20(+, diffuse), CD10(+) for follicle, Bcl-2(-) for follicle, CD23(-) and Cyclin-D1(-). According to all histopathologic findings, it is suggestive of reavtive hyperplasia and less likely lymphoma. However, repeat biopsy or excision is advised for further evaluation, if malignancy is still suspected clinically.
    • 2021-12-13 CT - abdomen
      • Thickening of right posterior pleura and prevertebral tissue at T9-12.
      • Increased soft tissue at left pubic cavity.
      • Portal hypertension and splenomegaly.
    • 2021-12-07 SONO - abdomen
      • Splenmegaly, marked
  • chemoimmunotherapy
    • 2022-10-24 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1200mg 30min + doxorubicin 50mg/m2 50mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD D1-5
    • 2022-09-30 - rituximab 375mg/m2 600mg 8hr + prednisolone 60mg/m2 5mg/tab 8# 40mg BID D1-5

[assessment]

  • There is evidence of splenomegaly, portal hypertension, and high bilirubin levels (direct and total), but the cause is not yet known.
  • Interstitial pattern and/or fibrosis at LUL has been observed. Rituximab has been associated with pulmonary disease and/or pulmonary toxicity. It might be necessary to monitor the lung status on a regular basis.
  • As far as the current prescription is concerned, there is no problem.

700141460

221024

  • chemoimmunotherapy
    • 2022-09-14 - irinotecan 150mg/m2 230mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3600mg 46hr

[assessment]

  • Coxine (isosorbide-5-mononitrate) has been prescribed for the patient’s high hs-Troponin I (241.8 pg/mL 2022-10-22) and CKMB (9.7 ng/mL 2022-10-22).
  • The most recent record of blood pressure was 100/52 (2022-10-24 08:41). The perfusion of vital organs, including the coronary arteries, might be compromised by low blood pressure. Saline 0.9% 500mL IVD PRNQD has been prescribed.
  • There is an impairment of renal function in the patient. Hemodialysis will be arranged by a nephrologist.
  • Currently, the serum potassium level is within the normal range (3.5 mmol/L 2022-10-22)
  • The blood calcium concentration of this patient is frequently below normal. The addition of some phosphate binders may be beneficial. Phosphate binders are categorized as calcium-containing and noncalcium-containing. Calcium-containing binders include calcium carbonate and calcium acetate. Major noncalcium-containing binders include sevelamer and lanthanum. Other agents include ferric citrate and sucroferric oxyhydroxide.

700511404

221024

  • past history (2022-10-22 adminnote)
    • DM
    • Hypertension
    • Left breast cancer s/p OP
    • GERD
    • Constipation
    • Hyperthyroidism
    • Breast cancer s/p C/T (bil leg numbness)
    • Multiple myeloma IgA kappa + lambda biclonce /p Ixazomib since 2022/7-2022/8 and lenalidomide 1# QOD and dexamethasone since 2022/7 to now.
  • exam findings
    • 2022-12-02 CT - brain
      • A skull defect at left temporal region. Some lucent lesions in skull.
      • Brain atrophy and lacunar infarct.
    • 2022-11-03 Myocardial perfusion SPECT with persantin
      • Probably mild myocardial ischemia at the apex.
      • Mild reverse redistribution of radioactivity to the anteroapical wall and posterior wall, either normal variant or myocardial ischemia may show this picture.
    • 2022-11-03 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (124 - 49) / 124 = 60.48%
        • M-mode (Teichholz) = 60
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, mild AR, mild TR
      • Mild pulmonary hypertension
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
      • Sinus rhythm at the exam
    • 2022-10-25 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — myeloma.
      • IHC stains: CD138: 60%; Kappa and Lambda light chains show a predominant lambda sub-population. CD34: <1 %; MPO: 30-40% (of the nucleated cells).
      • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and increase in the number of plasmacytoid cells. Megakaryocytes are adequate in number.
    • 2022-10-24 Abdomen
      • Spondylosis of the L-spine is noted.
      • Compression fracture of T12, L2, L4, and L5 are suspected.
    • 2022-10-22 CXR
      • Cardiomegaly and tortuosity of the thoracic aorta.
      • Widening of the mediastinum.
      • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-03-08 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Multiple myeloma
      • Microscopically, the bone marrow shows multiple myeloma characterized by hypercellularity (90%), 2:3 of M:E ratio and a proliferation of plasma cells (11~20%).
      • Immunohistocehmical stain reveals CD20(+, 15%), CD138(>10%), Kappa(-), Lambda(+), MPO(+), CD34(-), CD117(-) and CD71(+).
    • 2021-12-09 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • EM: 8.3mm.
    • 2021-03-05 Patho - bone marrow biopsy
      • Bone marrow, biopsy — <2% of CD138+ cells
      • Microscopically, it shows 30% of cellularity, 1:1 of M:E ratio, occasional normal megakaryocytes and <2% of CD138+ cells.
      • Immunohistochemical stain reveals CD138(<2%), CD71(+), MPO(+), CD117(-), CD34(-), CD20 (2~3%).
    • 2021-01-25 ENT Hearing Test
      • Reliabilty Fair
      • PTA
        • R’t : 58 dB HL
        • L’t : 50 dB HL
        • Bil mild to moderately severe SNHL
      • Tymp
        • R’t : Type As
        • L’t : Type C
      • ART
        • Bil absent.
    • 2020-10-20 ENT Hearing Test
      • Tymp bil type As
      • ART bil contra and RE ipsi absent, LE ipsi reduced thretholds
      • E- tube function bil poor
      • PTA:
        • Reliability FAIR
        • Average RE 60 dB HL, LE 50 dB HL
          • RE mild to severe SNHL
          • LE mild to moderately severe SNHL
      • RE tinnirus
    • 2020-10-20 OVEMP
      • oVEMP (ocular vestibular-evoked myogenic potential)
        • Bil show no response
      • cVEMP (cervical VEMP)
        • Bil show no response
    • 2020-10-20 Electronystagmography, ENG
      • no abnormal nystagmus
    • 2020-09-28 C-spine Lat. flex. and ext.
      • Osteoporosis. Spondylosis, esp C5-6-7.
    • 2020-08-28 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Compatible with plasma cell myeloma with partial remission
      • The sections show normocellular marrow (20%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology.
      • IHC, scattered CD138+ plasma cells in interstitium, account for <5% of marrow cells with lambda light chain restriction and negative for kappa light chain. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2020-04-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 44.1) / 112 = 60.63%
        • M-mode (Teichholz) = 60.6
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild aortic, mitral and tricuspid regurgitation
      • Dilated LA, thick IVS and LVPW
      • Impaired LV relaxation
    • 2020-04-09 Long bones series
      • Few osteopenic defects at bilateral radius, bilateral humerus, bilateral femur, bilateral fibular and bilateral scapular are suspected.
    • 2020-04-07 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Myeloma.
      • IHC stains: CD138 (+, 85-90% of the nucleated cells), kappa (+, 80-90%), lambda (<5%), MPO (<5%), CD117 (<1%)
      • Section shows one piece of bone marrow with 40-50% cellularity and a predominant plasmacytoid cells.
    • 2020-04-06 Patho - bone exostosis
      • Soft tissue and bone, L5 body and right upper sacrum, CT-guided biopsy — Plasma cell neoplasm, compatible with plasma cell myeloma
      • The sections show plasma cell neoplasm, composed of diffuse sheets of neoplastic round cells with abundant basophilic cytoplasm and eccentric nuclei. Occasional intranuclear inclusions (Dutcher body) can be found.
      • IHC, the neoplastioc cells reveal: CD138(+), cytokeration(-), lambda light chain(+), and kappa light chain(-). Suggest clinic correlation.
    • 2020-04-01 SONO - nephrology
      • right adrenal tumor, nature to be determined
    • 2020-03-31 MRI - L-spine
      • Small L4/5 central HIVD.
      • L2 compression fracture.
      • Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases
    • 2019-06-05 Color Transcranial Sonographic, CPA (carotid phonoangiograph)
      • Mild atheromatous lesions in bilateral ICAs and carotid bifurcations.
      • Normal extracranial carotid, vertebral arterial flows.
      • Poor bilateral temporal windows for transcranial insonation.
      • Normal other intracranial and bilateral ophthalmic arterial flows.
  • consultation
    • 2020-04-10 Rehabiliation
      • Q
        • Being unable to sit up in bed
      • A
        • Assessment
          • Multiple myeloma
          • Anemia
          • Hypercalcemia, improved
          • Hypertension
          • Diabetic mellitus (2020/3/13 HbA1c 6.6%)
        • Plans
          • Please treat the myeloma and related back pain as your expertise
          • Keep back brace use except when lying down
          • Rehabilitation programs: Bedside PT rehabilitation programs
            • Goal: better sitting/standing balance, ambulate with device under support
    • 2020-04-10 Radiation Oncology
      • A
        • A: Multiple myeloma with L spine and sacrum involvement.
        • P: Radiotherapy is indicated for this patient with the following indicators: Multiple myeloma with low back pain.
          • Goal: palliation.
          • Treatment target and volume: L2~L5 and sacrum.
          • Technique: IMRT
          • Preliminary planning dose: 2800cGy/14 fractions.
    • 2020-03-31 Hemato-Oncology
      • Q
        • For MRI showed Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases
        • This 73-year-old female with a past history of 1) DM 2) Hypertension 3) Left breast cancer s/p OP 4) Constipation, she had dizziness for half years, under regular Neuro OPD follow up. She was admitted due to severe low back pain, L-MRI showed Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases. We need your help for further management, thanks a lot.
      • A
        • This is a case of hypercalcemia. Mass over anterior L5 vertebral body was noted. MRI sifggested D/D of myeloma and metastasis.
        • Suggest check immunoglobulin profile (IgG, A, M, kappa/lambda light chain), tumor marker screening (CEA, CA199, CA153, CA125). We’ll follow up this case, if there is abnormal immunoglobulin profile, we’ll make diagnostic BM biopsy; otherwise, do tumor survey according tumor markers and do tumor mass mass biopsy is suggested.
    • 2020-03-31 Orthopedics
      • Q
        • for severe low back pain
      • A
        • consult for low back pain radiation to bilateral buttock and lower leg, weakness and paresthesia,unable to bear weight
        • Xray showed bil SI joint OAand decreased disc space and foramen of L5-S1 level
          • suggest pain control (Arcoxia 1# QD or even Dynastat Q12H x 3 days if severe pain + Mefno 1# QD + Neurontin 1# QD)
          • suggest L-spine MRI for further evaluation
          • contact me afteer MRI was done
    • 2020-03-24 Orthopedics
      • Q
        • Due to right lower back pain was noted for days, she also mentioned she was her CVA husband main care giver, we would like to need your visit to rule out orthologic disease. Thank you very much!
      • A
        • S: low back pain, radiation to bil buttock and thigh
        • O: tenderness. knocking pain+, muscle spasm, SLRT-X: L5-S1 narrow, bil SI arthritis
        • A: lumbar spondylosis, L5-S1 narrow, degeneration
        • P: Arcoxia 1# QD, Traumacet 1# bid, Neurontin 1# HS, use waist support
  • chemoimmunotherapy
    • 2022-04-21 ~ 2022-09-01 - Ninlaro (ixazomib) 3mg QWAC
    • 2022-04-14 ~ 2022-11-25 - Revlimid (lenalidomide) 25mg QOD
    • 2022-01-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2022-01-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2022-01-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2022-01-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-12-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-12-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-04 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-17 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-08-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-08-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-05-07 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-04-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-04-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-04-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-12 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-05 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-02-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-02-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-01-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-01-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-11-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-11-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-11-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-09-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-09-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-09-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-07-10 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-07-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-06-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-06-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-05-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-05-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-04-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-04-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-04-14 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-05-13 ~ 2022-04-14 - Thado (thalidomide) 100mg QN
    • 2020-07-03 ~ on and off - Xgeva (denosumab) 120mg Q1M SC

[assessment]

  • As the patient’s serum calcium levels have dropped into the normal range, it may be appropriate to hold or discontinue Miacalcic (calcitonin) if no other considerations exist.
    • 2022-12-05 Ca (Calcium) 2.39 mmol/L
    • 2022-12-04 Ca (Calcium) 2.74 mmol/L
    • 2022-12-03 Ca (Calcium) 3.25 mmol/L
    • 2022-12-02 Ca (Calcium) 3.25 mmol/L
  • For it has been observed that multiple data points of blood sugar levels exceeding 200 mg/dL since this hospitalization under current metformin treatment, the initialization of basal insulin is recommended.

701120825

221024

  • exam finding
    • 2022-10-21 ECG
      • Sinus tachycardia
      • Right atrial enlargement
      • Rightward axis
      • Possible Anterior infarct, age undetermined
      • Abnormal ECG
    • 2022-10-21 Nasopharyngoscopy
      • Tumor involving soft palate, bilateral palatine tonsil, tongue base, epiglottis, supraglottic region and nasopharyngeal roof. Bilateral vocal fold immobility with airway narrowing.
    • 2017-10-05 Whole body PET scan
      • Glucose hypermetabolism in a focal area in the left lower neck about level IV. A metastatic lymph node may show this picture.
      • Asymmetric FDG uptake in bilateral tonsils with a little more FDG uptake in the right tonsil. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, bilateral shoulders and right hip. Inflammatory process may show this picture.
    • 2017-07-17 MRI - larynx
      • A nodule or LN with central necrosis in left lower neck, level IV.
    • 2017-02-22 CT - neck, hypopharynx
      • several small lymph nodes in the right parotid space
    • 2016-04-23 CT
      • Post LNs dissection with soft tissue or muscle defect, right.
      • Small left neck LNs.
      • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass..
      • No obvious abnormal enhancement after contrast medium administration.
    • 2015-04-23 pathology
      • Tonsil, right, biopsy — Negative for malignancy.
      • Lymph node, neck level I, right, neck dissection — Negative for malignancy (0/2).
      • Salivary gland, submandibular, right, neck dissection — Negative for malignancy.
      • Lymph node, neck level II, right, lymphadenectomy with frozen section — Presence of metastatic carcinoma, in favor of non-keratinizing sqaumous cell carcinoma, with extranodal extension(1/1).
      • Lymph node, neck level II, III and IV, right, neck dissection — Negative for malignancy( 0/10).
      • Tissue labelled as “internal jugular vein”, right, neck dissection — Negative for malignancy.
      • Soft tissue, sternocleidomastoid muscle, right, neck dissection — Negative for malignancy.
  • consultation
    • 2022-10-22 Family Medicine
      • Q
        • The 64 y/o woman has head and neck non-keratinizing sqaumous cell carcinoma, with extranodal extension, regular at Mackey Hospital for supportive care. Deu to dyspnea, so she sent to our ED. Family favor hospice. We need your help. Thanks!
      • A
        • Dyspnea.
        • NOW with UFT 1# BID
        • Our share care would follow up.
    • 2022-10-21 ENT
      • Q
        • The 64 y/o woman has head and neck non-keratinizing sqaumous cell carcinoma, with extranodal extension, regular at Mackey for supportive care. Due to suspect air obstruction, we need your help for management.
      • A
        • Oral cavity: trismus with <1 FB.
        • Neck: stiffness, previous OP wound over right neck, an about 3cm tumor over rigt post-auricular region.
        • Scope: Tumor involving soft palate, bilateral palatine tonsil, tongue base, epiglottis, supraglottic region and nasopharyngeal roof. Bilateral vocal fold immobility with airway narrowing.
        • Impression: Head and neck malignancy with diffuse involvement.
        • Plan: Since the patient has signed DNR consent, palliative therapy is suggested for the patient.
  • surgical operation
    • 2015-04-23
      • Surgery
        • Radical neck dissection, right
        • Tumor mapping with right tonsil biopsy
      • Finding
        • Hypertrophy of lower pole of right tonsil, s/p biopsy.
        • 4x4cm capsulized tumor at right neck level II, severe adhesion to surrounding muscle and vessel, ruptured intra-operatively and some serous flowed out, which was sent for culture. The tumor was sent for frozen section. Frozen section = suspected squamous cell carcinoma
        • Lymphoareolar tissue at right level I, II, III, III as well as internal jugular vein, SCM were dissected out and removed. Spinal accessory nerve was preserved.

[assessment]

  • 2022-10-21 serum creatinine 0.39 mg/dL, eGFR 175, serum glucose 127 mg/dL. Glomerular hyperfiltration promoted by hyperglycemia? Muscle loss?
  • Celebrex (celecoxib) should be limited as short as necessary to prevent possible renal injury.

701370027

221024

[assessment]

  • eGFR was around 15 ~ 20 over the past half year (2022-04 ~ 2022-10), and the medication dosage has been adjusted accordingly.
  • There is no restriction on the use of nasogastric tubes in the administration of oral medications included in the active prescription.

700629294

221022

  • exam finding
    • 2022-10-22 CT - chest
      • No evidence of recurrent/residual tumor in the study
    • 2022-10-06 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • EM: 4.7mm.
    • 2022-07-22 Patho - breast simple/partial mastectomy
      • DIAGNOSIS:
        • A. Breast, right partial mastectomy with frozen section (F2022-337SA) — atypical ductal hyperplasia (ADH) with microcalcifciation.
          • IHC stains: CK5/6 (+, focal rim staining) p63 (rim staining).
        • B. Lymph node, sentinel, right, sentinel LN, s/p neoadjuvant chemotherapy (F2022-337FSC) — negative for malignancy. Two focus of fibrosis probably involuted lymph node after chemotherapy.
        • C. Breast, right, total mastectomy total mastectomy (S2022-11852) — scleroscing adenosis, fibrocystic disease, and adenosis.
      • MICROSCOPIC DESCRIPTION:
        • A. Sections F2022-337FSA1-2 show breast tissue with atypica ductal hyperplasia with microaclcification.
          • IHC stains: CK5/6 (+, focal rim staining) p63 (rim staining). Foci of scleroscing adenosis, fibrocystic disease, and adenosis are present.
        • B. Sections F2022-337FSC1-2 show fibroadipose tissue with moderate fibrosis.
        • C. Sections S2022-11852 show breast tissue with scleroscing adenosis, fibrocystic disease, and adenosis are present.
    • 2022-07-22 Patho - breast simple/partial mastectomy
      • Diagnosis
        • Breast, left, s/p neoadjuvant chemotherapy followed by total mastectomy (S2022-11851) — no residual malignancy
        • Resection margin: free:
        • Lymph node, left, sentinel lymph node biopsy with frozen section (F2022-337FSB) — free
        • yp T0 ypN0(sn) (if cM0)
      • Gross Description
        • Procedure - mtotal mastectomy with senteinel lymph nodes.
        • Lymph node sampling - sentinel lymph node(s)
        • Specimen laterality - Left
          • Sections are taken and labeled as:
            • Tissue for frozen sections: F2022-337FSB: left sentinel lymph nodes.
            • Tissue for formalifixation: S2022-11851A1-12: left breast.
      • Microscopic Description
        • For Invasive Carcinoma: no residual malignancy.
        • For Ductal Carcinoma In Situ: no DCIS
        • Margins: no residual malignancy
        • Nodal status: Negative (if lymph nodes are present in the specimen)
          • No. examined: 2
          • No. macrometastases (>2 mm): 0
          • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
          • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
          • In the Breast
            • No residual invasive carcinoma is present in the breast after presurgical therapy
          • In the Lymph nodes
            • No lymph node metastases and no prominent fibrous scarring in the nodes
        • Immunohistochemical Study: result of biopsy specimen: S2021-19572
          • IHC stains (using blockS2021-19572): ER(+ , 100%, strongintensity), PR(-), Her2/neu: positive(score=3+), Ki-67(70 %), p53(50%).
    • 2022-07-21 Frozen section
      • Preliminary diagnosis:
        • FSA1-2: right breast: irrregular duct. The possibility of malignancy cannot be excluded. Will need IHC stain to determine the nature of these ducts.
        • FSB: left sentinel LN s/p neoadjuvant therapy: free (0/2).
      • ADDENDUM:
        • FSC1-2: right sentinel LN, s/p neoadjuvant chemotherapy: negative for malignancy. Two focus of fibrosis probably involuted lymph node after chemotherapy.
    • 2022-07-21 Lymphoscintigraphy
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential dynamic and static images over the chest revealed at least one focal area of increased accumulation of radioactivity at the left axilla.
      • IMPRESSION: Probably at least one sentinel lymph node at the left axillary region.
    • 2022-07-07 Mammography
      • Impression:
        • Regression of left breast tumor (LIQ) and axillary lymph node.
        • Focal asymmetry in UOQ of right breast (posterior portion), stationary.
      • BIRADS 6
    • 2022-07-07 SONO - breast
      • Diagnosis
        • Bil. fibroadenomas as described
        • Left breast cancer
      • BI-RADS:
        • 6 - known biopsy-proven malignancy
    • 2022-06-11 CT - lung/mediastinum/pleura
      • IMP: No evidence of lung metastases based on this CT study.
    • 2022-01-25 2D transthoracic echocardiography
      • LVEF(%) = 72
    • 2022-01-14 CT - abdomen, pelvis
      • Left breast cancer with left axillary lymph node metastasis is highly suspected. please correlate with clinical condition.
      • The gallbladder shows mild irregular wall thickening and few stones that may be chronic inflammation. The differential diagnosis include gallbladder cancer.
    • 2021-12-28 Patho - breast biopsy
      • Breast, left, 5/2, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using blockS2021-19572): ER (+, 100%, strongintensity), PR(-), Her2/neu: positive (score=3+), Ki-67(70 %), p53 (50%).
    • 2021-12-28 Patho - lymphnode biopsy
      • Lymph node, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using blockS2021-19571): ER (+, 100%, strongintensity), PR(+, 30%, strong intensity), Her2/neu: positive (score=3+), Ki-67(90 %), p53 (60%).
    • 2021-12-28 SONO - breast
      • Bilateral breast irregular tumors, suspected malignancy, suggest biopsy.
      • Enlarged left axillary lymph node, suspected lymph node metastasis.
      • Suggest biopsy.
      • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
    • 2021-12-18 Mammography
      • BI-RADS category 0, Need additional imaging evaluation.
      • Suggest ultrasound correlation for developing left breast nodules and enlarged left axillary lymph node.
    • 2019-05-03 Mammography
      • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative.-annual screening.
  • consultation
    • 2022-03-31 ENT
      • Q
        • for right ear pain and headache
        • This 58 year-old woman panient suffered from left breast mass in 2021/11. Breast SONO on 2021/12/28 showed bilateral breast irregular tumors, suspected malignancy, suggest biopsy, enlarged left axillary lymph node, suspected lymph node metastasis and suggest biopsy. Left lymph node core biopsy showed invasive carcinoma, no special type, NST. IHC stains (using block S2021-19571): ER (+ , 100%, strongintensity), PR(+, 30%, strong intensity), Her2/neu: positive(score=3+), Ki-67(90 %), p53 (60%). Left 5/2 breast core biopsy showed Invasive carcinoma, no special type, NST. IHC stains (using block S2021-19572): ER (+ , 100%, strongintensity), PR(-), Her2/neu: positive(score=3+), Ki-67(70 %), p53 (50%).
        • This time, she was admitted to ward for chemotherapy with AC(C4) on 2022/03/31, then she complaints right ear pain and headache for 3-4 days, so we need your help for survey evulation, thanks a lot.
      • A
        • Eating on side(+, L) R otalgia with bil temple pain for 3 days.
        • PE:
          • Ear drum: bil intact
          • EAC: clean
          • TMJ: right TMJ tenderness when compression
        • Imp: TMJ syndrome
        • Plan: Pain control
  • surigcal operation
    • 2022-07-21
      • Surgery
        • bilateral simple mastectomy and SLNB
      • Finding
        • left breast cancer, HER-2 type, s/p neoadjuvant chemotherapy and target therapy, tumor regression, SLNB: negative of malignancy
        • right breast tumor, excision for frozen pathology: irrregular duct. The possibility of malignancy cannot be excluded. Will need IHC stain to determine the nature of these ducts –> do simple mastectomy and SLN sampling
    • 2018-07-05 PCS code 87003C
      • Benign neoplasm of skin of eyelid, including canthus
      • lid tumor, os
  • chemoimmunotherapy
    • 2022-10-18 - Herceptin (trastuzumab) 600mg SC
    • 2022-09-27 - Herceptin (trastuzumab) 600mg SC
    • 2022-09-06 - Herceptin (trastuzumab) 600mg SC
    • 2022-08-16 - Herceptin (trastuzumab) 600mg SC
    • 2022-06-29 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
    • 2022-06-10 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
    • 2022-05-16 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
    • 2022-04-22 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
    • 2022-04-01 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
    • 2022-03-11 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
    • 2022-02-15 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
    • 2022-01-25 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr

==========

2022-10-22

  • Trastuzumab administration (2022-04-22 ~ undergoing) might result in subclinical and clinical cardiac failure. The incidence and severity might be higher for patients received anthracycline-containing chemotherapy regimens (doxorubicin 2022-01 ~ 2022-04). An update of 2D transthoracic echocardiography is recommended (the most recent was performed on 2022-01-25 prior to the introduction of doxorubicin).

2022-05-17

  • The patient was diagnosed with breast cancer (ER+, PR (-, + lymph nodes) Her2/neu 3+) and has been treated with doxorubicin/cyclophosphamide followed by docetaxel/trastuzumab.
  • The last CT performed on 2022-01-14 showed a thickening of the gallbladder wall. Since gallbladder mets from breast cancer are rare, it might be sufficient to follow the gallbladder on an annual basis.
  • Lab data on 2022-05-10 showed that liver and kidney function, electrolytes and CBC were generally normal.
  • TPR readings remain stable during this hospital stay, no issues with active prescription.

700269001

221021

  • lab data
    • UGT1A1 6/7
    • Bilirubin total
      • 2022-07-14 Bilirubin total 0.70 mg/dL
      • 2022-06-16 Bilirubin total 1.30 mg/dL
      • 2022-04-21 Bilirubin total 0.60 mg/dL
      • 2022-04-07 Bilirubin total 0.98 mg/dL
      • 2022-03-31 Bilirubin total 0.98 mg/dL
      • 2022-03-22 Bilirubin total 1.18 mg/dL
      • 2022-03-09 Bilirubin total 2.15 mg/dL
      • 2022-02-24 Bilirubin total 1.44 mg/dL
      • 2022-02-09 Bilirubin total 1.22 mg/dL
      • 2022-01-26 Bilirubin total 1.27 mg/dL
      • 2021-12-30 Bilirubin total 0.98 mg/dL
      • 2021-12-25 Bilirubin total 0.78 mg/dL
  • exam finding
    • 2022-08-29 CT - abdomen, pelvis
      • Rectal cancer s/p operation. Minimal ascites in pelvic cavity.
    • 2022-07-15 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 18 dB HL, LE 21 dB HL
      • bil normal to moderate SNHL
    • 2022-07-08 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average R’t 13 dB HL, L’t 31 dB HL
      • R’t normal to mild SNHL.
      • L’t normal to moderately severe SNHL.
      • Tymp: Bil type A.
      • ART: R’t WNL.
      • L’t 500 Hz reduced thresholds.
    • 2022-07-01 Pure Tone Audiometry, PTA
      • Reliabilty Fair
      • R’t: 19 dB HL, WNL except 8k Hz
      • L’t: 45 dB HL, mild to moderately severe SNHL.
    • 2022-06-23 Hearing Test
      • Reliabilty Fair
      • PTA - Pure Tone Audiometry
        • R’t: 18 dB HL, normal to moderate SNHL
        • L’t: 46 dB HL, normal to moderately severe SNHL
      • Tymp - Tympanogram
        • Bil Type A
      • ART - Acoustic reflex threshold
        • R’t: Ipsi absent
        • L’t: Ipsi 500-1k Hz reduced, contra absent.
    • 2022-05-23 Patho - colon segmental resection for tumor
      • pathologic diagnosis
          1. Tumor, lower rectum, Robotic Abdominal Perineal Resection — Residual intramucosal adenocarcinoma
          1. Resection margins, ditto — Free of tumor
          1. Lymph nodes, mesocolic, dissection — Free of tumor metastasis (0/8)
          1. AJCC pathologic stage — ypTisN0, stage 0, if cM0
      • macroscopic examination
        • Tumor appearance: elevated mucosa
        • Depth of invasion grossly: lamina propria
      • microscopic examination
          1. Histology: residual intramucosal adenocarcinoma
          1. Histology Grade: G1, well differentiated
          1. Depth of invasion: lamina propria
          1. Angiolymphatic invasion: not identified
          1. Perineural invasion: not identified
          1. Discontinuous extramural tumor extension: absent
          1. Circumferential (radial) margin of rectosigmoid: Not involved
          1. Lymph node metastasis, mesocolic: free of tumor metastasis (0/8)
          1. Lymph node metastasis, IMA / SMA: N/A
          1. Extranodal involvement: N/A
          1. Pathological TNM Stage: ypTisN0
          1. Type of polyp in which invasive carcinoma arose: N/A
          1. TNM descriptors: y
          1. Tumor regression grading S/P CCRT: grade 2 (rare residual cancer)
    • 2022-05-23 SONO - abdomen
      • Liver calcification nodules (incomplete exam of liver)
    • 2022-05-19 ECG
      • Normal sinus rhythm
      • RSR or QR pattern in V1 suggests right ventricular conduction delay
      • Borderline ECG
    • 2022-04-07 CT - abdomen, pelvis
      • History and indication:
        • Rectal cancer s/p CCRT suspected low rectal cancer at anterior; 1.5*1.5 cm with ulceration and bleeding at 3 cm from AV
      • IMP:
        • Mild regression of rectal cancer.
    • 2022-04-07 Colonoscopy
      • Findings
        • The scope reach the S-colon.
        • Rectal cancer s/p CCRT with tumor regression at anterior wall, 4cm from AV
      • Diagnosis
        • Rectal cancer s/p CCRT with tumor regression
    • 2022-03-24 Cardiac Catheterization
      • Type of arrhythmia
        • WPW
      • Ablation Diagnosis
        • Intermittent Wolff-Parkinson-White syndrome (iWPW), s/p successful cryoablation of para-Hisian accessory pathway through non-coronary cusp (NCC) approach
    • 2022-03-14 SONO - abdomen
      • suspected liver parenchymal disease, mild fatty liver
      • liver calcification nodules
    • 2022-02-17 ECG
      • Sinus rhythm with frequent Premature ventricular complexes in a pattern of bigeminy
      • Fusion complexes
    • 2022-01-28 Cardiopulmonary Exercise Testing
      • summary:
        • maximal exercise
        • normal exercise capacity ( VO2 99%, WR 118%)
        • normal stroke volume response during exercise
        • normal ventilatory function ( FVC 127%, FEV1 118%)
        • normal respiratory muscle strength (MIP 75%, MEP 89%)
      • suggestions:
        • treat underlying condition
        • survey and treat cardiac function, refer to CV for EKG with ST-T changes
        • arrange pulmonary rehab with exercise training
    • 2022-01-12 CXR
      • A calcified spot at RUQ.
    • 2021-12-28 Patho - colon biopsy
      • Colon, dentate line to 8 cm AAV at anterior wall, biopsy — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • 2021-12-28 Colonoscopy
      • Diagnosis
        • Highly suspected rectal cancer, 1/4 circumference, from dentate line to 8 cm AAV at anterior wall, s/p biopsy
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2021-12-27 CT - abdomen, pelvis
      • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T3N0M0, stage IIA
  • consultation
    • 2022-01-18 Psychosomatic Medicine
      • Q
        • This 57-year-old woman patient is a case of low rectal cancer arising from dentate line with broad-based villous tumor up to 8 cm from AV cT3N0M0; stage II. She was admitted for concurrent chemoradiotherapy. For evaluate anxiety with insomnia therapy. Thank you.
      • A
        • Psychiatric impression:
          • depression and anxiety
          • suspected adjustment reaction with anxiety and depression
        • Psychiatric history:
          • This 57-year-old woman patient is a case of low rectal cancer cT3N0M0; stage II was diagnosed in December 2021. This time she was admitted for concurrent chemoradiotherapy. We were consulted due to anxiety and insomnia were noted.
          • According to the patient, she suffered from low mood, anxiety and worry about the cancer treatement (enteroproctia, artificial anus). surgical treatment, fearfulness, anticipatory anxiety, negative thought, free floating anxiety, poor appetite and poor sleeplasting (1-2 hour), suicide ideation before.
          • MSE: coherent and relevent speech, fair spontaneous speech, anxiety and low mood, negative thinking, worrisome, denied panic like attack.
        • Suggestion:
          • emotional support and empthy
          • may give Mirtapine (mirtazapine) 0.5# HS and alprazolam 0.5# prn if anxiety
          • arrange psychiatric OPD (patient request W1 evening OPD)
  • radiotherapy
    • 2022-01-10 ~ 2022-02-23 - Concurrent radiotherapy 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed area.
  • chemoimmunotherapy
    • 2022-10-20 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-09-30 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-09-07 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-08-26 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-08-12 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-07-29 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-07-15 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-07-01 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr (oral mucostatis with ulcer with pain for 2 weeks, upper and lower limbs numbness in 2022-06)   
    • 2022-04-11 - oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + 2400mg/m2 3600mg 46hr
    • 2022-03-09 - oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + 2400mg/m2 3600mg 46hr
    • 2022-02-14 - Leucovorin 20mg/m2 10min D1~2 + 5-FU 400mg/m2 10min D1~2; CCRT
    • 2022-02-09 - Leucovorin 20mg/m2 10min D1~3 + 5-FU 400mg/m2 10min D1~3; CCRT
    • 2022-01-17 - Leucovorin 20mg/m2 10min D1~3 + 5-FU 400mg/m2 10min D1~3; CCRT
    • 2022-01-13 - Leucovorin 20mg/m2 10min D1~2 + 5-FU 400mg/m2 10min D1~2; CCRT

[note]

  • All You Need to Know About UGT1A1 Genetic Testing for Patients Treated With Irinotecan: A Practitioner-Friendly Guide ( https://ascopubs.org/doi/full/10.1200/OP.21.00624 )
    • Irinotecan is an anticancer agent widely used for the treatment of solid tumors, including colorectal and pancreatic cancers. Severe neutropenia and diarrhea are common dose-limiting toxicities of irinotecan-based therapy, and UGT1A1 polymorphisms are one of the major risk factors of these toxicities.
    • In 2005, the US Food and Drug Administration revised the drug label to indicate that patients with UGT1A128 homozygous genotype should receive a decreased dose of irinotecan. However, UGT1A128 testing is not routinely used in the clinic, and specific reasons include lack of access to concise information on this wide issue as well as mixed recommendations by regulatory and professional entities.
    • To assist oncologists in assessing whether and when to use UGT1A1 genetic testing in patients receiving irinotecan-based therapies, this article provided (1) essential knowledge of UGT1A1 polymorphisms; (2) an update on the impact of UGT1A1 polymorphisms on efficacy and toxicity of contemporary irinotecan-based regimens; (3) dosing adjustments based upon the UGT1A1 genotypes, and (4) recommendations from currently available guidelines from the US and international scientific consortia and major oncology societies.

[assessment]

  • FOLFOX regimen has been modified by lowering oxaliplatin dose (65mg/m2 <- 85mg/m2) and skipping fluorouracil bolus since July 2022 due to mucositis and limb numbness observed in June 2022.
  • Oral mucositis is appropriately treated with Nincort Oral Gel (triamcinolone) currently.
  • Duloxetine is recommended for the mitigation of chemotherapy-induced peripheral neuropathy (ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)
  • Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily. (ref: UpToDate)

700514824

221021

[assessment]

  • Since the patient began her hospital stay, her blood sugar levels have exceeded 200 mg/dL in all data points ( with a record high 401 mg/dL) under current basal/bolus insulin therapy.
  • In this case, it is recommended to gradually increase the basal insulin by 2 or 3 units and monitor the changes in blood sugar levels to determine whether further adjustments are necessary.

700999894

221021

  • diagnosis
    • 2022-10-18 discharge note
      • Right lower lobe lung cancer, adenocarcinoma, T2bN0M0, stage IIA, status post operation, with recurrent rT4N2M1a, stage IVA with lung to lung metastasis, ECOG 1, EGFRmutation: L858R (-), exon 19 (-), ALK(-), ROS1(-)
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
      • Insomnia, unspecified
      • Malignant neoplasm of lower lobe, right bronchus or lung
      • Chronic obstructive pulmonary disease
      • Chronic rhinitis
  • History
    • hypertension under regular control for 2-3years (at LMD)
    • RLL lung cancer,adenocarcinoma, pStage IIA, pT2bN0(cMx)s/p VATS RLL lobectomy + RLND on 20170904, diagnosed on 20170908 ECOG:1; EGFR mutation wild type; Alk negative; PDL1 <1%.
      • post operation adjuvent chemotherapy:
        • immunotherapy Keytruda 20171006 ~ 20190603
        • chemotherapy with C1D1D8 Navelbine (20171007 and 20171031);
        • Gemzar total 6 cycle (20171030 ~ 20180501);
        • CDDP total 4 cycle (201761103, 20171127, 20180302, 20180503);
        • Vinorelbine total 6 cycle (20180528, 20180621, 20180726, 20180821, 20180914, 20181012)
      • For lung cancer re-staging, the chest CT was performed, wich multiple nodular lesions of varying sizes in both lungs shown, favor recurrent lung tumor with lung to lung metastasis.
        • Brain MRI and whole body bone scane also done without brain or bone metastasis.
      • For tissue prove, thet thoracoscopic wedge or Partial resection of the Lung on 20190315 and the pathogen disclosed Adenocarcinoma.
        • Therefore, the progression lung cancer pT2bN0 staage IIA -> rT2bN0M1a Stage IV was diagnosed.
      • For progression lung cancer, we was re-challenge the chemotherapy to immunotherapy C1 with Tecentriq (Atezolizumab), chemotherapy C1 Alimta, C1 Avastin and C1 CDDP since 201904.
      • The chest film showed ill-defined nodular/masses lesions of varying sizes in both lungs, recurrent lung cancer with lung to lung metastases, in progression on 20220907.
    • The lung cancer treatment regimen as below:
      • 1st chemotherapy with C1 Alimta, C1 Avastin and C1 CDDP since 201904
      • 2nd chemotherapy with C1 Docetaxel since 20220913.
      • immunotherapy C1 with Tecentriq since 201904, and changed to double immunetherapy with C1 Nivo total 200mg (free) IVF on 20210304 and Ipilmumab total 50mg (charge) IVF on 20210305.
  • chemoimmunotherapy
    • 2022-10-14 - Yervoy (ipilimumab) 50mg 30min
    • 2022-10-14 - Opdivo (nivolumab) 200mg 1hr
    • 2022-10-13 - Nolboxol (docetaxel) 25mg/m2 40mg 1hr
    • 2022-09-15 - Yervoy (ipilimumab) 50mg 30min
    • 2022-09-14 - Opdivo (nivolumab) 200mg 1hr
    • 2022-09-13 - Nolboxol (docetaxel) 25mg/m2 40mg 1hr
    • 2022-06-30 - Yervoy (ipilimumab) 50mg 30min
    • 2022-06-29 - Opdivo (nivolumab) 200mg 1hr
    • 2022-06-28 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-06-27 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-06-08 - Yervoy (ipilimumab) 50mg 30min
    • 2022-06-07 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-06-06 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-04-29 - Yervoy (ipilimumab) 50mg 30min
    • 2022-04-28 - Opdivo (nivolumab) 200mg 1hr
    • 2022-04-27 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-03-24 - Yervoy (ipilimumab) 50mg 30min
    • 2022-03-23 - Opdivo (nivolumab) 200mg 1hr
    • 2022-03-22 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-03-21 - Cyramza (ramucirumab) 10mg/mg 600mg 90min
    • 2022-02-24 - Yervoy (ipilimumab) 50mg 30min
    • 2022-02-23 - Opdivo (nivolumab) 200mg 1hr
    • 2022-02-22 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-02-21 - Cyramza (ramucirumab) 10mg/mg 600mg 90min
    • 2022-01-21 - Yervoy (ipilimumab) 50mg 30min
    • 2022-01-20 - Opdivo (nivolumab) 200mg 1hr
    • 2022-01-19 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-01-19 - Cyramza (ramucirumab) 10mg/mg 600mg 90min

701356390

221021

{breast cancer with brain mets}

  • cheif complaint (2022-09-16 adminnote)
    • Gait disturbance within recent half month, headedness, headache, poor memory, left hand tremor also noted.
  • present illness (2022-09-16 adminnote)
    • The skin-sparing mastectomy with immediate breast reconstruction was done on 2007-11-26.
      • The pathological report showed the diagnosis of Invasive Lobular Carcinoma. The stage was pT2N0M0, Stage IIA, with ER (4+), PR (4+), Her-2 IHC (1+).
    • The adjuvant treatement was LHRH agonist (Zoladex) from 2007-12-27 to 2012-12-13.
    • The anti-estrogen, tamoxifen, was added from 2012-06-28 to 2013-01-10.
    • On 2018-03-21, she sustained a mass over left supraclavicular area.
    • On 2018-03-26, the whle body bone scan showed the possibility of bone mets over left anterior 1st and 2nd ribs.
    • The denosumab (XGEVA) was given from 2018-03-29 to now.
    • The palbociclib plus letrozole was given 2018-04-26 to 2018-11-06.
    • On 2018-06-27, the Chest CT scan revealed necrotized mass over the left uper anterior mediastinum with direction invasion to left antirior 1st and 2nd ribs, which might explain the findings of increasing tracer uptake in the whole body bone scan on 2018-06-27 and later on 2018-08-21.
      • It indicated the recurrence of invasive lobular carcinoma over mediastinum, The treatment was at SD, based on the findings of CT on 2018-10-16.
    • On 2018-10-26, the PET-CT demonstraged: 1. a huge hypermetabolic mass wiht central necrosis, abunting anterior chest wall and possible invsding sternum in the anterior mediastinum; 2. several hypermetaboic nodes in the left supraclavicular, left para-sternal and left lower pleura, indicating nodal metastases or pleural seeding.
    • The sono-guided biopsy on 2018-11-02 disclosed metastaic poorly differentiated carcinoma, with ER (30%), PR (-), Her-2 (<10%), Ki-67 (<3%)
    • On 2018-12-25, the thyroid sonography revealed bilateral multinodular gioter, without evident malignancy by aspiration cytology. The weekly eribulin for 2 weeks every 3 weeks was given from 2018-11-07 to 2019-10-09.
    • The letrozole from hospital and palbociclib from outside hospital were resumed from 2019-12-04 to now.
    • On 2019-03-14, the follow-up PET-CT showed marked regression of prepericardial and left intercostal LAPs, mild regression of the anterior mediastinal mass.
    • To maximize the anti-cancer effect, the radiotherapy to the anterior mediastinal mass was given with 45 Gy/18Fx was given from 2019-04-02 to 2019-04-25.
    • On 2019-09-18, the follow-up PET-CT showed partial regression of the anterior mediastinal mass and invisibility of those aforementioned LAPs.
    • On 2020-04-01, the follow-up CT showed the metastases of mass and LAP in PR.
    • On 2021-04-26, the follow-up PET-CT showed the metastases of mass and LAP in PR.
    • She suffered from lower limbs weakness, and visited our ER on 2022-01-10. Brain CT on 2022/01/10 showed c/w brain metastasis and midline shift, 8mm. Brain MRI on 2022-01-10 showed intra-axial lesions, R/O brain metastasis.
    • Brain CT on 2022-01-12 showed multiple brain metasatses with mass effect. S/P markers for stereostatic surgery. Stereotactic biopsy and aspiration for right PO cystic lesion and left frontal deep tumor on 2022-01-13
      • CSF pathology suspicious for adenocarcinoma,
      • Brain pathology showed metastatic carcinoma, breast origin ,
        • Immunohistochemistry shows CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal) for tumor cells, compatible with metastatic breast carcinoma.
    • Abdominal CT on 2022-02-11 showed 1. S/P Mastectomy, left. There is soft tissue swelling at the left upper anterior mediastinum, nature? please correlate with clinical condition. 2. Detailed findings, please see description.
    • Whole body bone scan on 2022-02-14 showed two hot spots in bilateral fronto-parietal region of the skull, respectively, and increased activity in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?).
    • Plan to deliver 30 Gy/ 10 fractions to the whole brain from 2022/01/24~2022/01/28 for 15 Gy/ 5 fractions.
    • Xgeva 1pc SC on 2022/01/27, 2022/02/24, 2022/03/24, 2022/04/19.
    • Received palliative chemotherapy with Q3W Adriamycin(60mg/m2)/Cyclophosphamide(600mg/m2) on 2022/02/24(C1), 2022/03/16(C2), 2022/04/07(C3), 2022/04/27(C4), 2022/05/17(C5), 202206/07(6).
    • Chemotherapy with QW Docetaxel(35mg/m2) on 2022/06/30(C1), 2022/07/14(C2), 2022/07/28(C3), 2022/08/11(C4),2022/09/01(C5).
    • Brain MRI on 2022/08/10 showed 1.unremarkable change in the intraventricular and extraventricular CSF spaces; 2.solid and rim-enhnaincg lesions in the left frontal lobe, 22mm; left cindulate gyrus,14.8mm; right cerebellar hemisphere, 5.7mm. right parieto-occipito-temporal lobe, 42.3mm. The small one in the left parietal lobe on the previous study on 20220510 was missing. The solid nodule in the left frontal lobe was increased in size; 3. unremarkable change in the skull base.
    • She suffered from gait disturbance within recent half month, headedness, headache, poor memory, left hand tremor also noted. She came to NS OPD for help on 2022/09/09.
    • Brain CT was done showed: 1.mild dilated intraventricular and extraventricular CSF spaces, 2.two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe, 3.unremarkable change in the skull base.
    • Now, she was admitted to ward for radiotherapy evaluate and change chemotherapy regimen for disease progression.
  • past history
    • Breast cancer s/p about 15 year ago, s/p OP and radiotherapy with bone and lymph node metastases s/p chemotherapy with brain metastasis s/p radiotherapy
    • Left lymph node s/p biospy, about 2 year ago. under Hormones and Targeted Therapy. Re-follow CT show Left lymph node and clavicle metastasis.
    • Hypertension for 10 years with Novrasc 1# po QD and Bisoprolol 1.25mg 1# po QD
    • Diabetes for 10 years with Glimet(glimepiride 2mg+metformin 500mg) 1# po QD.
  • exam finding
    • 2022-10-20 CT - abdomen
      • Partial consolidation at LLL suspected pneumonia.
      • Colon diverticula. Fat stranding abutting S-colon suspected diverticulitis.
      • Left ovary cyst (5.2cm).
    • 2022-10-07 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (99.8 - 21.7) / 99.8 = 58.82%
        • M-mode (Teichholz) = 78.3
      • Adequate LV,RV systolic function with normal wall motion
      • Mild PR
      • Impaired LV relaxation
    • 2022-09-09 CT - brain
      • mild dilated intraventricular and extraventricular CSF spaces
      • two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.
      • unremarkable change in the skull base
    • 2022-08-19 CT - chest
      • Left breast cancer with chest wall meta s/p left mastectomy, C/T and R/T. The chest wall meta is stationary .
    • 2022-08-10 MRI - brain
      • multiple brain metastasis with some stationary; one missing ; the solid one, increase in size.
    • 2022-08-01 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the skull, both rib cages, sternum, lower L-spine, sacrum, bilateral shoulders, S-I joints, hips and knees.
    • 2022-05-24 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/02/25, the previous two hot spots in the skull are a little less evident. However, no prominent change is noted in the lesions in the sternum.
      • Suspected benign lesions in lower L-spines, sacrum, bilateral shoulders, S-I joints, hips and knees.
    • 2022-05-19 CT - chest
      • Left anterior chest wall soft tissue lesion. Stationary.
      • S/P mastectomy at left side.
      • Radiation pneumoniitis at left upper lobe
    • 2022-05-10 MRI - brain
      • At least 7 intra-axial lesions, mixed solid and cystic components, in bilateral cerebral hemispheres and right cerebellar hemisphere. 5.6mm of the largest one in right posterior temporal lobe. Enhancement of the solid part after contrast administration.
      • compatible with breast cancer with brain metastases.
    • 2022-02-25 Ventricular ejaction fraction and wall motion study
      • The RVEF and LVEF were 63% and 65% respectively.
      • Normal wall motion of the LV.
    • 2022-02-24 transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (121 - 51.2) / 121 = 57.69%
      • Adequate LV,RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild PR,TR
    • 2022-02-14 Tc-99m MDP whole body bone scan
      • Two hot spots in bilateral fronto-parietal region of the skull, respectively, and increased activity in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in lower L-spine, sacrum, bilateral shoulders, S-I joints, and hips.
    • 2022-02-11 CT - whole abdomen, pelvis
      • S/P Mastectomy, left.
      • There is soft tissue swelling at the left upper anterior mediastinum, nature?
    • 2022-01-13 Patho - brain biopsy
      • Brain tumor, r’t frontal area, frozen section and biopsy - Metastatic carcinoma, breast origin
      • IHC: CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal) for tumor cells, compatible with metastatic breast carcinoma.
        • There is NO amplification of HER2 detected by FISH assay in Taipei Institute of Pathology
    • 2022-01-13 Frozen section
      • Tumor, brain, frozen section - Malignancy, poorly-differentiated.
    • 2022-01-12 CT - Brain for navigator
      • Multiple brain metasatses with mass effect. S/P markers for stereostatic surgery.
    • 2022-01-10 MRI - Brain for navigator
      • Intra-axial lesions, suspected brain metastasis
    • 2022-01-10 CT - Brain
      • c/w brain metastasis
      • Midline shift, 8mm
    • 2021-04-26 PET
      • metastases of mass and LAP in PR.
    • 2020-04-01 CT
      • metastases of mass and LAP in PR.
    • 2019-09-18 PET
      • partial regression of the anterior mediastinal mass and invisibility of those aforementioned LAPs.
    • 2019-03-14 PET
      • marked regression of prepericardial and left intercostal LAPs, mild regression of the anterior mediastinal mass.
    • 2018-12-25 Sonography - thyroid
      • bilateral multinodular gioter, without evident malignancy by aspiration cytology.
    • 2018-11-02 Patho - sono-guided biopsy
      • metastaic poorly differentiated carcinoma
      • ER (30%), PR (-), Her-2 (<10%), Ki-67 (<3%)
    • 2018-10-26 PET
      • a huge hypermetabolic mass wiht central necrosis, abunting anterior chest wall and possible invading sternum in the anterior mediastinum
      • several hypermetaboic nodes in the left supraclavicular, left para-sternal and left lower pleura, indicating nodal metastases or pleural seeding.
    • 2018-10-16 CT
      • SD - stable disease
    • 2018-08-21, -06-27 Whole body bone scan
      • increasing tracer uptake
      • it indicated the recurrence of invasive lobular carcinoma over mediastinum
    • 2018-06-27 CT - chest
      • necrotized mass over the left uper anterior mediastinum with direction invasion to left antirior 1st and 2nd ribs
    • 2018-03-26 Whole body bone scan
      • possibility of bone mets over left anterior 1st and 2nd ribs.
    • 2018-03-21 Presentation
      • she sustained a mass over left supraclavicular area.
    • 2007-11-26 Patho - skin-sparing mastectomy
      • Invasive Lobular Carcinoma. The stage was pT2N0M0, Stage IIA,
      • IHC: ER (4+), PR (4+), Her-2 (1+).
  • surgical operation
    • 2022-01-13 Stereotactic biopsy and aspiration for right PO cystic lesion and left frontal deep tumor; breast cancer history (+);
      • finding
        • OP 1:
          • Two pieces white-grayish soft tumor was harvest at left forntal deep brain.
          • Frozen section: Tumor, brain, frozen section - Malignancy, poorly-differentiated.
        • OP 2:
          • Xanthochromic then light reddish fluid about 40cc was apirated at right PO area.
          • sent for cytology/culture and CSF profile.
    • 2007-11-26 skin-sparing mastectomy with immediate breast reconstruction
  • radiotherapy
    • 2022-02-07 medrec plan to deliver 30 Gy/ 10 fx to the whole brain.
    • 2022-01-24 ~ 2022-01-28 - the whole brain 15 Gy/ 5 fractions?
    • 2019-04-02 ~ 2019-04-25 - 45 Gy/18Fx to the anterior mediastinal mass
  • chemotherapy
    • 2022-10-21 ~ 2022-10-24 - Granocyte (lenograstim) 250mg QD SC
    • 2022-10-20 - G-CSF (filgrastim) 150mg ST SC
    • 2022-10-07 - Lipo-Dox (liposome doxorubicin) 50mg/m2 80mg 2hr
    • 2022-09-01 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-08-11 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-07-28 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-07-14 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-06-30 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-06-07 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-05-17 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-04-27 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-04-13 ~ 2022-04-15 - Granocyte (lenograstim) 250mg QD SC
    • 2022-04-07 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-03-21 ~ 2022-03-23 - Granocyte (lenograstim) 250mg QD SC
    • 2022-03-16 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-02-24 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2019-12-04 ~ undergoing ? palbociclib + letrozole
    • 2018-11-07 ~ 2019-10-09 - weekly eribulin for 2 weeks every 3 weeks
    • 2018-04-26 ~ 2018-11-06 - palbociclib + letrozole
    • 2018-03-29 ~ on-and-off - Xgeva (denosumab)
      • 2022-01-27, 2022-02-24, 2022-03-24, 2022-04-19, 2022-05-17, 2022-06-16, 2022-07-28, 2022-08-13, 2022-09-16
    • 2012-06-28 ~ 2013-01-10 - anti-estrogen tamoxifen
    • 2007-12-27 ~ 2012-12-13 - LHRH (luteinising hormone releasing hormone) agonist Zoladex (goserelin)

==========

2022-10-21

  • Grade 4 neutropenia (2022-10-21 WBC 20 cells/uL) is observed. The patient has been received lenograstim and filgrastim.
  • As the disease itself and its metastases evolve, their characteristics are changing
    • 2007-11-26 patho - mastectomy: ER(4+), PR(4+), Her2(1+).
    • 2018-11-02 patho - sono-guided biopsy: ER(30%), PR(-), Her2(<10%), Ki-67(<3%)
    • 2022-01-13 patho - brain biopsy: CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal)
  • A brain MRI on 2022-08-10 revealed that a solid mass had increased in size. Researchers have demonstrated that trastuzumab deruxtecan had a high intracranial response rate in patients with active brain metastases associated with HER2-positive breast cancer (ref: Trastuzumab deruxtecan in HER2-positive breast cancer with brain metastases: a single-arm, phase 2 trial. Nat Med 28, 1840–1847 (2022). https://doi.org/10.1038/s41591-022-01935-8). Upon confirmation that Her2 is positive, trastuzumab deruxtecan may be considered as a treatment option.
  • The blood sugar level records showed a monotonic increase (331 <- 265 <- 208 mg/dL). In addition to current used Galvus Met (metformin and vildagliptin), acarbose, glimepiride or basal insulin is recommended. The SGLT2i would not be preferred for her since she recently experienced a UTI event.

2022-10-13

  • During this hospital stay, all data points of serum glucose before meal were above 220mg/dL and a 368mg/dL peak record was observed.
  • Metformin/vildagliptin is currently being taken by the patient. There is a recommendation to add alpha-glucosidase inhibitors, e.g., acarbose, SGLT-2 inhibitors, such as canagliflozin, dapagliflozin (use SGLT2i if no more UTI concern), or a basal insulin therapy.

2022-09-19

  • This patient had received doxorubicin/cyclophosphamide (6, 2022-02-24 ~ 2022-06-07) and docetaxel (5, 2022-06-30 ~ 2022-09-01)

  • Brain MRI (2022-08-10) showed one solid mets increased in size and brain CT (2022-09-09) showed mild dilated intraventricular and extraventricular CSF spaces and two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.

  • Pathology (2022-01-13) comfirmed breast cancer brain mets triple negative. Neither trastuzumab and its biosimilars/ADC(antibody drug conjugates) nor CDK4/6 inhibitors (e.g., ribociclib, palbociclib) might likely to show effective.

  • National Health Insurance covers PARP (poly ADP-ribose polymerase) inhibitors like olaparib and talazoparib for metastatic triple negative breast cancer with BRCA1/2 mutations since 2022-08-01.

  • For patients with triple-negative brain metastases from breast cancer (BCBM), two chemotherapy regimens seem to show specific CNS activity:

    • the anti-vascular endothelial growth factor agent bevacizumab plus paclitaxel in a small Phase 2 study (70% ORR but only 6 patients with triple negative MBC) and the microtubule inhibitor eribulin in case reports.
    • A Phase 2 trial presented at ASCO 2013 highlighted a combination of bevacizumab plus carboplatin in the treatment of BCBM. In this study, 38 patients were treated with bevacizumab plus carboplatin, and trastuzumab was added if the tumour was HER2+. The composite brain ORR was 63% and the global ORR was 45%.
    • For these HER2– patients, therefore, standard chemotherapy comprising capecitabine, eribulin or carboplatin plus bevacizumab can be used for progressive BM after local treatment.
    • ref: Bailleux, C., Eberst, L. & Bachelot, T. Treatment strategies for breast cancer brain metastases. Br J Cancer 124, 142–155 (2021). https://doi.org/10.1038/s41416-020-01175-y

2022-04-08

  • The patient has TNBC with brain mets and is being treated with doxorubicin and cyclophosphamide as from late February 2022.
  • In lab results reported on 2022-04-06, liver and kidney functions were normal, and no obvious abnormalities were noted in the CBC or WBC levels.
  • If the current regimen fails to produce satisfactory outcome, capecitabine might be a subsequential alternative.
  • Olaparib or talazoparib might be an optional add-on if the BRCA1/2 mutation germline sequencing result is positive.
  • Phase III KEYNOTE-355 trial demonstrated the benefits of pembrolizumab added to chemotherapy in locally advanced or metastatic triple-negative breast cancer.

2022-03-17

701450829

221021

  • exam findings
    • 2022-10-20 CT - abdomen
      • Cecal cancer with colostomy, peritoneal seeding, LNs, liver and lung metastases. Compression fracture of T12.
    • 2022-10-20 KUB
      • Lumbar spondylosis.
      • T12 compression fracture.
    • 2022-10-20 CXR
      • Increase bilateral lung markings.
      • Mild cardiomegaly.
      • Thoracic spondylosis and scoliosis.
      • T12 compression fracture.
    • 2022-10-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 32.2) / 109 = 70.46%
        • M-mode (Teichholz) = 70.5
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild MR, mild TR and PR
      • AV sclerosis with mild AR , trivial AS
      • Possibly mild pulmonary HTN
      • No regional wall motion abnormalities
    • 2022-10-04 ECG
      • Sinus rhythm with Fusion complexes
      • T wave abnormality, consider inferior ischemia
    • 2022-10-04 CXR
      • Multiple nodules at bil. lungs.
    • 2022-09-26 Patho - colon biopsy
      • Colon, hepatic flexure, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show a picture of adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
      • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2022-09-23 Colonoscopy
      • One tumor mass (4-5 cm in size) was noted in thehepatic flexure withlumen narrowing (80 cm from anal verge).
    • 2022-09-16 CT - abdomen
      • History: Mild epigastric discomfort and fullness, acid reflux, weight loss due to decrease intake, microcytic anemia was noted at OPD post transfusion
        • 20220915 sono: A 71.8x57.8 mm hypoechoic heterogeneous mass lesion at the RT lobe liver. Suspected HCC
        • 20220916 CA125: 97.2 U/mL (<35), CA199: 1896 U/mL (<35), AFP: normal.
      • Findings:
        • There is circumferrential asymmetrical wall thickening at the cecum, proximal ascending colon, ileocecal valve, and terminal ileum with irregular contour, measuring 4.7 x 6.8 cm in size.
          • Cecal cancer (T4a) is highly suspected. Please correlate with colonoscopy.
          • In addition, there are several enlarged nodes in the adjacent mescolon (T2a).
        • There are heterogeneous poor enhancing masses in S5 and S6 of the liver and the largest one measuring 8 cm in size. It is c/w liver metastasis.
          • In addition, there are two soft tissue nodules in LLL and LUL of the lung that are c/w lung metastases.
          • There are two small soft tissue nodule in the omentum of RMQ and lower pelvis that may be tumor seeding (M1C).
        • There is mild ascites in the cul-de-sac.
        • A renal cyst measuring 2.9 cm in left upper pole is noted.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
    • 2022-09-15 Sonography - abdomen
      • hepatic tumor favor HCC
      • susp. parenchymal liver disease.
  • consultation
    • 2022-10-21 Family Medicine
      • Q
        • The 85 y/o woman has ascending colon cancer with liver, peritoneal seeding, LNs, liver and lung metastases, stage IVc (cT4aN2aM1c) status post laparoscopy with loop-ileostomy on 20221006. Family need information for hospice care. Thanks! 64749陳宣妃
      • A
        • DNR(-) The patient is unaware of the situation?
        • Our share care would follow up.

700997286

221020

{ovarian cancer s/p debulking surgery}

  • discharge diagnosis
    • 2022-07-22
      • 1: Ovarian cancer s/p Debulking surgery (bilateral salpingo-oophorectomy + omentectomy + peritoneal tumor excision + bilateral inguinal mass excision) on 2021/11/09, pT3cN0M1b, Stage IVB s/p chemotherapy with Taxaol/Carboplatin(from 2021/12/15~2022/03/16 for 9 cycles), PD
      • 2: Major depressive disorder, single episode, severe with psychotic features
      • 3: Delusional disorders
      • 4: Hypomagnesemia
  • drug allergy
    • Ibuprofen Injection 100mg/ml,4ml/amp: angioedema
    • Voren 12.5mg/supp (diclofenac sodium): angioedema
  • exam finding
    • 2022-08-04 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Progression of peritoneal/abdominal wall seeding, retroperitoneal and pelvic recurrence.
      • Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region.
    • 2022-06-10 Patho - lymph node region resection
      • Lymph node, left inguinal, excision — metastatic ovarian high-grade serous adenocarcinoma (2/2)
      • Section shows pieces of lymph nodes with metastatic papillary tumor cells.
      • The immunohistochemical stains reveal PAX8(+), WT-1(+), and p53 (aberrant expression).
      • The results are in favor of metastatic ovarian high-grade serous adenocarcinoma.
    • 2022-06-02 ECG
      • Minimal voltage criteria for LVH, may be normal variant
      • Borderline ECG
    • 2022-04-25 ECG
      • Sinus rhythm with Premature atrial complexes
      • Incomplete right bundle branch block
      • T wave abnormality, consider anterior ischemia
      • Prolonged QT
    • 2022-04-25 CT - abdomen, pelvis
      • Findings
        • S/P hysterectomy. Some soft tissue masses in retroperitoneum and pelvic cavity.
        • Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region.
        • Some fluid at operative wound site.
        • Left renal stone (2mm).
      • Impression
        • S/P hysterectomy. Recurrent tumors in retroperitoneum and pelvic cavity. Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region. Some fluid at operative wound site.
    • 2022-04-14 2D transthoracic echocardiography
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR,TR,PR
      • Mild Pulmonary HTN
    • 2022-03-23 CT - abdomen, pelvis
        1. Recurrent serous adenocacinoma in left inguinal area.
        1. Metastatic nodes in para-aortic space, aortocaval space, Lt common iliac chain, and Lt external iliac chain.
        1. There are lobulated cystic lesions in the pelvis and smuddgy appearance of the omentum that may be residual tumor seeding (carcinomatosis)?
    • 2021-12-13 Pure Tone Audiometry, PTA
      • Reliabilty Fair
      • R’t : 15 dB HL
      • L’t : 10 dB HL
      • Bil WNL.
    • 2021-11-09 Patho - soft tissue tumor, extensive resection
      • Pathologic diagnosis
        • Ovary, right, salpingo-oophorectomy —- serous adenocarcinoma, high grade.
        • Ovary, left, salpingo-oophorectomy —- serous adenocarcinoma, high grade.
        • Fallopian tube, right, salpingo-oophorectomy —- serous adenocarcinoma, high grade. By seeding.
        • Fallopian tube, left, salpingo-oophorectomy —- serous adenocarcinoma, high grade. By seeding.
        • Uterus — absent – post hysterectomy
        • Omentume, omentectomy —- serous adenocarcinoma, high grade.
        • Douglous pouch mass, tumor excision — serous adenocarcinoma, high grade.
        • Para-rectal mass, tumor excision — serous adenocarcinoma, high grade.
        • Omentum mass x 2, tumor excision — serous adenocarcinoma, high grade.
        • Right inguinal mass, tumor excision — serous adenocarcinoma, high grade.
        • Left inguinal mass, tumor excision — serous adenocarcinoma, high grade.
        • An addendum report of the consensus pathological stage will be followed after tumor board meeting.
        • The consensus pathology tumor staging of gynecology tumor board meeting on Nov. 18, 2021: pT3c pNx pM1b, FIGO stage: IVB.
      • Microscopic examination
          1. Histologic type: serous adenocarcinoma
          1. Histologic grade: high grade
          1. Contralateral ovary involvement: present
          1. Tumor side ovarian surface involvement: present
          1. Contralateral ovary surface involvement: present
          1. Right tube involvement: present (on serosa)
          1. Left tube involvement: present (on serous and in parenchyma)
          1. In situ adenocarcinoma in right and/or left fallopian tube: absent
          1. Right adnexa soft tissue involvement: present
          1. Left adnexa soft tissue involvement: present
          1. Pelvic soft tissue involvement: present: 3). central pelvic mass; 4). Douglous pouch mass; 5). para-rectal mass x 2)
          1. Uterine serosa involvement: non-applicable (previous hysterectomy; no uterus received)
          1. Omentum involvement: present.
          1. Uterine Cervix involvement: not received
          1. Endometrium involvement: not received
          1. Myometrium involvement: not received
          1. Appendix involvement: not received
          1. Largest Extrapelvic Peritoneal Focus - Macroscopic (2 cm or less)
          1. Peritoneal/Ascitic Fluid-Not submitted.
          1. Regional Lymph Nodes: No lymph nodes submitted
          1. Other organs or specimens involvement: present. 7). right inguinal mass; 8). left inguinal mass.
    • 2021-09-22 Patho - ovary (tumor)
      • Pelvic mass, CT-guide biopsy — Adenocarcinoma
      • Microscopically, the sections show a picture of adenocarcinoma characterized by pleomorphic and hyperchromatic tumor cells arranged in papillary or soild pattern.
      • Immunohistochemistry shows CK7(+), CK20(-), PAX-8(+, focal), WT-1(+) and calretinin(-) for tumor cells, serous carcinoma originating from adnexa maybe first considered. Please check GYN condition and clinical correlation is advised.
    • 2021-06-17 CT - abdomen, pelvis
      • S/P hysterectomy. Some soft tissue masses (up to 6.2cm) in peritoneal cavity (esp. pelvic cavity) suspected peritoneal seeding. Suspected liver metastases.
    • 2021-05-13 Gynecologic ultrasonography
      • pelvis mass 57x50mm, RI:0.22, ATH
      • suspect pelvis mass
  • consultation
    • 2022-05-06 Plastic and Reconstructive surgery
      • Q
        • The 61 y/o woman has ovary cancer with recurrent tumors in retroperitoneum and pelvic cavity. Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region. Some fluid at operative wound site. We confirm GYN, who suggested debridement, so we need your help. Thanks!
      • A
        • I will check on her next Monday. Thanks.
    • 2022-05-05 Infectious Disease
      • Q
        • The 61 y/o woman has ovarian cancer with peritoneal sign and fistula with fungating. Due to spiked fever noted, so we hold Tapimycin and shift to Meropenam and Targocid for infection control. We need your agree. Thanks!
      • A
        • keep present antibiotic Rx, and adjust to culture data later
        • monitor CRP
  • chemoimmunotherapy
    • 2022-10-19 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
    • 2022-09-13 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
    • 2022-08-18 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
      • topotecan dosing
        • package insert: Ovarian cancer and SCLC:
          • Initial Dose: The recommended dose of topotecan is 1.5 mg/m2 body surface area/day administered by intravenous infusion over 30 minutes daily for 5 consecutive days with a 3 week interval between the start of each course.
          • Subsequent Dose: Preconditions: Neutrophil >= 10^9/L, PLT >= 100*10^9/L, HGB >= 9 g/dL
        • UpToDate: Ovarian cancer, metastatic: IV: 1.5 mg/m2/day for 5 consecutive days every 21 days, continue until disease progression or unacceptable toxicity (ten Bokkel Huinink 2004) or (off-label dosing) 1.25 mg/m2/day for 5 days every 21 days until disease progression or unacceptable toxicity or a maximum of 12 months (Sehouli 2011) or (weekly administration; off-label dosing) 4 mg/m2 on days 1, 8, and 15 every 28 days until disease progression or unacceptable toxicity or a maximum of 12 months (Sehouli 2011).
    • 2022-07-21 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
    • 2022-06-22 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
    • 2022-04-14 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
    • 2022-03-16 - paclitaxel 80mg/m2 100mg 1hr + carboplatin AUC 2 220mg 2hr
    • 2022-03-09 - paclitaxel 80mg/m2 100mg 1hr + carboplatin AUC 2 190mg 2hr
    • 2022-02-23 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 190mg 2hr
    • 2022-02-16 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 190mg 2hr
    • 2022-01-19 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2022-01-12 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2022-01-05 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2021-12-22 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2021-12-15 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
  • lab data
    • WBC
      • 2022-10-19 WBC 7.13 *10^3/uL
      • 2022-09-08 WBC 4.19 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-09-20,21,22
      • 2022-08-19 WBC 7.81 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-08-25,26,27
      • 2022-08-16 WBC 5.49 *10^3/uL
      • 2022-08-09 WBC 1.92 *10^3/uL
      • 2022-08-02 WBC 2.73 *10^3/uL
      • 2022-07-21 WBC 4.34 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-07-27,28,29
      • 2022-07-14 WBC 3.21 *10^3/uL
      • 2022-07-07 WBC 1.18 *10^3/uL
      • 2022-06-22 WBC 9.33 *10^3/uL
      • 2022-06-20 WBC 9.86 *10^3/uL
      • 2022-06-02 WBC 10.30 *10^3/uL
      • 2022-05-09 WBC 3.54 *10^3/uL
      • 2022-05-02 WBC 7.09 *10^3/uL
      • 2022-04-29 WBC 1.11 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-04-29,30,2022-05-01,02
      • 2022-04-25 WBC 2.31 *10^3/uL
      • 2022-03-30 WBC 4.38 *10^3/uL
      • 2022-03-16 WBC 4.55 *10^3/uL
      • 2022-03-09 WBC 8.12 *10^3/uL
      • 2022-02-23 WBC 3.27 *10^3/uL
      • 2022-02-16 WBC 3.12 *10^3/uL
      • 2022-02-09 WBC 2.45 *10^3/uL
      • 2022-01-19 WBC 2.91 *10^3/uL
      • 2022-01-12 WBC 3.56 *10^3/uL
      • 2022-01-05 WBC 4.00 *10^3/uL
      • 2021-12-22 WBC 5.48 *10^3/uL
      • 2021-11-29 WBC 10.34 *10^3/uL
      • 2021-11-10 WBC 10.67 *10^3/uL
      • 2021-11-07 WBC 8.92 *10^3/uL
      • 2021-10-04 WBC 6.82 *10^3/uL
      • 2021-09-13 WBC 5.54 *10^3/uL
      • 2021-08-05 WBC 6.03 *10^3/uL
      • 2021-04-28 WBC 5.37 *10^3/uL

[assessment]

  • Grade 2 neutropenia (ANC <1.5 *10^3/uL) has not been observed since mid-August 2022 as a result of the administration of G-CSF in late August and September 2022.
  • The use of electrolyte supplements is appropriate in the treatment of hypokalemia (3.1 mmol/L 2022-10-19) and hypomagnesemia (1.6 mg/dL 2022-10-19).

2022-08

  • WBC and regiemn:
    • 2022-08-09 WBC 1.92 *10^3/uL <– 2022-07-21 liposome doxorubicin + carboplatin
    • 2022-07-07 WBC 1.18 *10^3/uL <– 2022-06-22 liposome doxorubicin + carboplatin
    • 2022-04-29 WBC 1.11 *10^3/uL <– 2022-04-14 liposome doxorubicin + carboplatin
  • During the 2 to 3 weeks after receiving [liposome doxorubicin 40 mg/m2 + carboplatin AUC 5], severe neutropenia was observed, whereas during the prior nine cycles of [paclitaxel 80 mg/m2 + carboplatin AUC 2], there was no such severe neutropenia observed.

700335277

221018

{DLBCL, diffuse large B-cell lymphoma}

  • past history
    • Systemic disease: CAD (coronary artery disease), 2VD s/p POBA (plain old balloon angioplasty) + DES (drug eluting stent) at prox to mild LAD (left anterior descending artery) and POBA to distal LCX (left circumflex artery) on 20210906, paroxysmal atrial fibrillation and atrial flutter, hypertension, benign prostatic hyperplasia  
  • exam finding
    • 2022-10-02 ECG
      • Atrial fibrillation
      • Minimal voltage criteria for LVH, may be normal variant
      • Abnormal ECG
    • 2022-09-21 MRI - larynx
      • An enhancing lesion (9 mm) at C2 vertebral body. Stationary as compared with MRI on 20220316. Suggest regular follow-up.
    • 2022-09-04 ECG
      • Sinus rhythm with 1st degree A-V block
      • Moderate voltage criteria for LVH, may be normal variant
      • Borderline ECG
    • 2022-08-22 CXR
      • Borderline cardiomegaly
    • 2022-08-08 ECG
      • Atrial flutter with variable A-V block
      • Abnormal ECG
    • 2022-08-03 ECG
      • Atrial fibrillation
      • Nonspecific ST abnormality
    • 2022-08-01, 2022-07-29, 2022-07-26 CXR
      • Borderline cardiomegaly
    • 2022-07-26 2D transthoracic echocardiography
      • LVEF(%) = 65
      • Conclusion:
          1. Normal LV systolic function with normal wall motion.
          1. Concentric LVH, severely dilated LA; LV diastolic dysfunction Gr 2.
          1. Normal RV systolic function.
          1. Aortic valve sclerosis with no AS, moderate AR; moderate MR; mild to moderate TR; mild PR.
          1. Possible mild pulmonary hypertension, estimated PASP: 37 mmHg.
          1. Mildly dilated ascending aorta.
    • 2022-07-25 ECG
      • Sinus rhythm with 1st degree A-V block
      • Early repolarization
    • 2022-07-24 ECG
      • Atrial fibrillation with a competing junctional pacemaker
    • 2022-07-24 CXR
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage. Suggest clinical correlation.
    • 2022-06-23 CXR
      • S/P port-A implantation. Otherwise, there is no significant abnormality of the chest.
    • 2022-05-17 CXR
      • Elevation of both hemidiaphragms
      • Skin fold over Rt hemithorax
      • Crowding of vascular markings and/or reticular opacities over lung fields
    • 2022-03-22 EKG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2022-03-16 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Hypercellularity (50%)
      • Microscopically, the bone marrow shows hypercellularity with hemopoietic components accounting for about 50% of the marrow space, M/E ration of 1~2: 1 and presence of trilineage component. Megakaryocytes are occasionally seen.
      • Immunohistochemical stain reveals MPO(+), CD34(-),CD117(-), CD138(<5%), CD20 (focal+, <3%), Bcl-2(-), Bcl-6(-), CD71(+).
    • 2022-03-14 ECG
      • Sinus rhythm with 1st degree A-V block
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-03-14 2D transthoracic echocardiography
        1. Normal AV with moderate AR
        1. Normal MV with mild MR
        1. LV septal hypertrophy
        1. Preserved LV and RV systolic function
        1. Mild PR, mild TR, normal IVC size
        1. Dilated LA
    • 2022-02-24 Whole body PET scan
      • There was increased FDG uptake involving the left tonsil and some left upper neck lymph nodes.
      • The FDG PET findings are compatible with lymphoma involving the left tonsil and some left upper neck lymph nodes.
    • 2022-02-22 ECG
      • Sinus rhythm with 1st degree A-V block
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-02-16 Tc-99m MDP whole body bone scan
      • Several hot or faint hot spots in the left lower temporal region of the skull, right rib cage, right S-I joint, L/3, and right acetabulum, respectively, the nature is to be determined (post-traumatic change or othr nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in some middle to lower C-spine, L4 spine, L-S junction, bilateral shoulders, elbows, left knee, and left foot.
    • 2022-02-14 Patho - tonsil and/or ademoid
      • Tonsil tumor, left, biopsy — Diffuse large B-cell lymphoma
      • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli and focal tumor necrosis
      • Immunohistochemistry: CK(-), P16(-), P63(+, scatter), CD3(-), CD20(+, diffuse), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), C-MYC(+, 20-30%) tumor.
    • 2022-02-11 CT - neck
      • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T2N0M0, stage II
    • 2022-02-11 Neck Soft Tissue
      • Film(s) of neck soft tissue shows:
        • Degeneration and spondylosis of C-spine.
        • A calcified spot at left neck.
    • 2022-02-11 ECG
      • Sinus rhythm with 1st degree A-V block
      • Otherwise normal ECG
    • 2022-02-11 Nasopharyngoscopy
      • smooth NPx, moderate obstruction at velum level, smooth OPx, HPx, airway mild compromised
    • 2021-09-07 ECG
      • Sinus rhythm with 1st degree A-V block
      • Otherwise normal ECG
    • 2021-09-06 ECG
      • Sinus bradycardia with 1st degree A-V block
    • 2021-09-06 Cardiac Catheter
      • Intervention Summary
        • LAD P-M, Pre-DS = 70%
          • MLD/RVD=/3.5 mm mm → /3.5 mm, Post Balloon DS = 50%%.
            • Guiding catheter: Boston 6F CLS3.5.
            • Guide Wire: Terumo Runthrough Floopy.
            • Guide Wire2: Asahi SION BLUE.
            • Balloon: B Braun NSE alpha balloon. 3.5 X 13mm mm. Pressure: 12 atmospheres. 43 secs.
            • Balloon2: Abbott NC Trek. 3.5 X 20mm mm. Pressure: 9 atmospheres. 30 secs.
            • Balloon3: Medtronic NC Euphora. 4.0 X 12mm mm. Pressure: 22 atmospheres. 15 secs.
            • Stent: B Braun Coroflex ISAR DES. 3.5 X 28mm mm. Pressure: 14 atmospheres. 14 secs.
            • Stent-MLD/RVD=/3.5 mm Stent DS = 0% residual stenosis.
        • LCX-D, Pre-DS = 80%
          • MLD/RVD=/2.5mm mm → /2.5 mm, Post Balloon DS = 30%%.
            • Guiding catheter: Boston 6F CLS3.5.
            • Guide Wire: Terumo Runthrough Floopy.
            • Guide Wire2: Asahi SION BLUE.
      • In conclusion: CAD DVDs/p PCI with DES for proximal to mid LAD and POBA for distal LCX, successful
      • Recommendation: PCI for LAD and LCX
    • 2021-09-03 2D transthoracic echocardiography
        1. Preserved LV and RV systolic function with normal wall motion
        1. Dilated LA, grade 2 LV diastolic dysfunction
        1. Mild AR, MR, TR
    • 2021-09-01 ECG
      • Sinus rhythm with 1st degree A-V block
    • 2021-08-27 19:52 ECG
      • Atrial fibrillation
      • Abnormal ECG
    • 2021-08-27 17:26 ECG
      • Atrial flutter with variable A-V block
      • Abnormal ECG
    • 2021-08-01 ECG
      • Atrial fibrillation
      • Abnormal ECG
    • 2021-05-31 ECG
      • Sinus bradycardia with 1st degree A-V block with Premature supraventricular complexes
    • 2021-04-14 Vestibular Evoked Myogenic Potential, VEMP
      • oVEMP Interaural Amplitude Asymmetry ratio 22.78 %,WNL
      • cVEMP Interaural Amplitude Asymmetry ratio 8.98 %, WNL
    • 2021-04-06 C-spine AP + Lat.
      • Radiograph of the cervical spine (AP and lateral):
        • Osteoporosis.
        • Spondylosis, esp C4-5-6-7.
    • 2020-07-28 Myocardial perfusion SPECT with persantin
      • Probably mild to moderate myocardial ischemia with possible a portion of severe ischemia at the inferolateral wall and posterior wall and mild myocardial ischemia at the apical lateral wall.
    • 2020-07-17 CXR
      • Spondylosis of the T-spine
      • Atherosclerotic change of aortic arch
    • 2020-07-17 ECG
      • Sinus rhythm with 1st degree A-V block
      • Minimal voltage criteria for LVH, may be normal variant
      • Borderline ECG
    • 2019-12-20 KUB
      • The psoas shadow is clear.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • Increased intestinal gas is found.
      • Phlebolith at pelvic cavity is also found.
      • Suggest clinical correlation
    • 2019-12-10 Surgical pathology Level III
      • Clinical diagnosis: Other cellulitis & absess, leg, except foot
      • Pathologic diagnosis
        • Benign
        • Skin and soft tissue, right lateral calf, regional fasciectomy — necrotizing inflammation
    • 2019-12-10 Surgical pathology Level III
      • Clinical diagnosis: Benign neoplasm of connective and other soft tissue, unspecified
      • Pathologic diagnosis
        • Benign
        • Tumor, chest, excision — Neurofibroma
    • 2017-11-14 Knee Bilat. standing
      • Moderate osteoarthritis of both knees with varus configuration
      • Ahlback calcification: grade 3, 3
  • consultation
    • 2022-06-29 Cardiology
      • Q
        • for hypertension poor control
        • This 78-year-old male, a pt of DLBCL, Lungano stage II, Dx in Feb 2022, suffered from initial presentation of enlarged neck near thyroid in Jan 2022. He was admitted due to port-A infection for anti treatment. Owing to hypertension poor control (SBP:200-206)/DBP(90) was noted during admission. We need expertise to evaluate his condition thanks!
      • A
        • S:
          • He also suffered Zoaster with neuropathic pain in T4-6 dermatome region from back to chest with large surface area, now in healing stage, but neuropathic pain remains but can tolerate. He also has port A removal site pain. He felt headache when in hypertension. He also has mild right ankle joint pain but not inflammed on inspection.
          • Denied of chest and abdominal pain. shortness of breath.
        • O
          • BP: near control till 20220627 then elevated upto 200/90 in 2022/06/27-28.
          • HR: average 70
          • Bed side BP during visit: 155/78-169/81
          • Current medication
            • po candesartan 1# qn
            • po atenolol 1# qd
            • po lasix 1# qd
          • Lab
            • Renal and electrolyte : normal
        • Impression
          • Elevated blood pressure in prior HCVD patient suspected neuropathic and post op pain related.
          • Port A infection with psuedomonas infection
        • Suggestion
          • please add po norvasc 1# qd for BP and hold If SBP < 140mmHg (observe ankle swelling which could be worsen due to norvasc side effect)
          • educate patient if home BP is relatively lower than 140mmHg. and also, if recurrent zoaster infection, then visit dermatologist for UV radiation that fasten healing and reduce neuropthic pain.
          • Adequate pain control.
    • 2022-05-10 Dermatology
      • Q
        • For herpes zoter
        • This 78-year-old man, a patient of DLBCL (triple-hit lymphoma) at L tonsil, Lungano stage II, IPI: 1, non-GCB subtype, Dx in Feb 2022, suffered from initial presentation of enlarged neck near thyroid in Jan 2022 S/P C/T. He was admitted for C/T. He complained of pain & herpes zoter over right chest, armpit, back for 3 days. We need expertise to evaluate his condition thanks!
      • A
        • This patient suffered from grouped vesicels on R’t trunk for 3 days.
        • Imp: Herpes zoster
        • Suggestion:
            1. Famvior 1 / Tid
            1. Lyrica * 1 /Bid
            1. ZnO* 1 tube/bid
    • 2022-02-11 ENT
      • Q
        • Sore throat > blood pressure or heartbeat is different from the patient’s usual value, however hemodynamics is stable, tonsils are suppuration, and there is no improvement after visiting local clinics.
          • throat pain noted for days
          • no fever
          • odynophagia(+)
          • no vomiting
        • PH: HTN; Af ; CAD
        • NKA
        • s/p 2nd Moderna last Dec.
      • A
        • S
          • Odynophagia, VAS 4-5 for a week.
          • Fever(-) Dypsnea(-)
        • O
          • PE:
            • Oral: swelling of left tonsil with exudate, swelling of left soft palate s/p aspiration(no pus)
            • Scope: smooth NPx, moderate obstruction at velum level, smooth OPx, HPx, airway mild compromised
        • Imp: Suspect left peritonsillar abscess
        • Plan:
            1. Neck CT with/without contrast (last meal: 20220211 11:40)
            1. OA to ENT, IV Curam + Genta
            1. Monitor airway
  • chemoimmunotherapy
    • R-DA-EPOCH, Dose-adjusted EPOCH-R ([etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin] + rituximab). Titration up: etoposide, doxorubicin, cyclophosphamide
    • 2022-10-18 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1285mg 30min D5 + prednisolone 60mg/m2 tmg/tab 20# QD D1-5
    • 2022-09-19 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1285mg 30min D5 + prednisolone 60mg/m2 tmg/tab 20# QD D1-5
    • 2022-08-22 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1300mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
    • 2022-07-26 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5 (vincristine not available then)
    • 2022-05-03 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
    • 2022-04-12 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
    • 2022-03-17 - rituximab 375mg/m2 640mg 8hr + etoposide 40mg/m2 68mg 24hr D1-4 + doxorubicin 6mg/m2 10mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5

==========

2022-09-19

[drug identification]

One drug for identification.

  • It is identified as Doudart (dustasteride 0.5mg + tamsulosin 0.4mg).
  • In men, it is used to treat the signs of an enlarged prostate.

The drug will be sent back to ward by the in-hospital porter.

2022-08-23

  • During this hospitalization, the blood pressure was around (180+-30)/(85+-10) with prescribed Norvasc (amlodipine 5mg) 1# QD, Blopress (candesartan 8mg) 1# QN and self-carried Urosin (atenolol 100mg) QD. If HTN still becomes symptomatic, thiazide diuretics such as Tricozide (trichlormethiazide 2mg/tab) 1# QD or Natrilix (indapamide 1.5mg/tab) 1# QD might be also considered.
  • Renal denervation is another BP-lowering strategy in hypertensive patients with high CV risk, such as resistant or masked uncontrolled hypertension, established ASCVD, intolerant or nonadherent to antihypertensive drugs, or features indicative of neurogenic hypertension after careful clinical and imaging evaluation (COR IIa, LOE B).

2022-07-25

  • There is a history of cardiovascular disease in the patient, 2022-03-14 2D transthoracic echocardiography showed: Mild PR, mild TR, Dilated LA, grade 2 LV diastolic dysfunction.
  • There were elevated levels of hs-Troponin I and NT-proBNP in the lab data that might indicate cardiovascular conditions.
    • hs-Troponin I
      • 2022-07-24 58.3 pg/mL
      • 2022-07-24 59.4 pg/mL
      • 2022-02-11 36.3 pg/mL
    • NT-proBNP
      • 2022-07-24 847 pg/mL
      • 2020-12-31 194 pg/mL
  • Doxorubicin was initialized at 6mg/m2 (2022-03-17) and titrated up to 9mg/m2 (2022-04-12), this is a relatively conservative and robust way of administration, last dose was administered on 2022-05-03.
  • Control of blood pressure was better than last hospitalization for there was no event of a SBP exceeding 200 mmHg and/or a DBP exceeding 100 mmHg.

2022-03-25

[drug identification]

Two drugs need identification.

the 2 identified items has been shown as following:

  • Duodart (tamsolosin 0.4mg, dutasteride 0.5mg)
  • Urosin (atenolol 100mg)

these drugs will be sent back to ward by an in-hospital porter.

700805995

221018

{Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB, s/p Laparoscopic gynecologic oncology staging surgery.}

  • exam finding
    • 2022-10-18 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 12) / 93 = 87.10%
        • LVEF (%) = 87
        • M-mode (Teichholz) = 87
      • Normal LV systolic function with normal wall motion.
      • LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Mild MR; mild TR; aortic valve sclerosis
    • 2022-09-16 CXR
      • Scoliotic alignment of the thoracolumbar spine is noted.
    • 2022-09-16 Peripheral Vascular Test - AV fistula
      • adequate size of RUV
    • 2022-08-23 Patho - uterus with or without SO
      • PATHOLOGIC DIAGNOSIS
        • Endometrium, uterus, LSC staging surgery — Endometrioid carcinoma, grade 2
        • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
        • Uterus, cervix, ditto — Free of tumor, 5.2 cm away from tumor
        • Ovary, right, ditto — Tumor invasion
        • Fallopian tube, right, ditto — Free of tumor
        • Ovary, left, ditto — Free of tumor
        • Fallopian tube, left, ditto — Free of tumor
        • Lymph node, left iliac, dissection — Free of tumor metastasis (0/9)
        • Lymph node, left oburator, ditto — Tumor metastasis (1/6) with extracapsular extension (1/1)
        • Lymph node, right iliac, ditto — Free of tumor metastasis (0/9)
        • Lymph node, right oburator, ditto — Free of tumor metastasis (0/14)
        • Omentum, omentectomy — Tumor invasion
        • AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB
      • MICROSCOPIC EXAMINATION
        • Histology type: Endometrioid carcinoma
        • Histology grade: Grade 2
        • Depth of invasion: more than half thickness of myometrium
        • Lymphovascular invasion: Present
        • The cervical stroma involvement: Absent
        • Resection margins of the cervix: Free, 5.2 cm away from tumor
        • Additional pathologic findings: focal tumor necrosis and focal squamous differentiation
        • Lymph nodes: tumor metastasis (1/38) with extracapsular extension (1/1) in total number
        • Uterine cervix: Free of tumor, chronic cervicitis
        • L’t ovary: corpus albicans and free
        • R’t ovary: tumor invasion
        • Bilateral fallopian tubes: Free of tumor
        • Omentum: tumor invasion characterized by scant tumor measured less than 0.1 cm with stromal inflammation. Immunohistochemistry of CK(+) for tumor
    • 2022-08-22 Body fluid cytology - ascites
      • diagnosis
        • Malignancy
      • macroscopic examination
        • 40 cc grey-orange cloudy ascites
      • microscopic examination
        • The smears show lymphocytes, reactive mesothelial cells and some hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
    • 2022-08-18 MRI - pelvis
      • Imaging Report Form for Endometrial Carcinoma
      • Imaging stage : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIc(Stage_value)
      • Imperssion: Uterine tumor with lymph nodes, suspected endometrial malignancy with lymph nodes metastasis, cstage T1bN1aM0, IIIc.
    • 2022-08-08 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C — endometrioid adenocarcinoma, grade 1.
      • IHC stains: ER (+, 100% strong intensity), PR (+, 90%, strong intensity), vimentin (+), P53 (wild type), Napsin-A (-), CK20 (-).
  • surgical operation
    • 2022-08-08
      • Surgery
        • D&C, theraputic and diagnostic, vaginal bleeding 
        • Pathology: pending
      • Finding
        • Uterus: Anteversion, 7 cm.
        • Some endometrial tissue were curetted out.
        • Estimated blood loss: 10 mL
        • Blood transfusion: nil
        • Complication: nil.  
  • radiotherapy
    • 2022-09-28 ~ undergoing? 1980cGy/11 fractions of the pelvic area.
  • chemoimmunotherapy
    • 2022-10-17 - doxorubicin 50mg/m2 77mg 30min + cisplatin 50mg/m2 77mg 2hr (Q3W)
    • 2022-09-21 - paclitaxel 160mg/m2 250mg 3hr + carboplatin AUC 5 490mg 2hr (Q3W, paclitaxel first 160mg/m2, full 175mg/m2)
      • After admission, she took pre-medication as Dorison 20mg at 20220920 2300 and 20220921 0500. She received Taxel (Initial 160mg/m2) and Carboplatin AUC 5 on 20220921.
      • When the Taxel drip around 11 ml, she has dyspnea and mild SOB. We stopped chemotherapy and IVF hydration.
      • Under the stable condition, she can be discharged on 20220922. OPD follow up is arranged.

700866748

221014

  • diagnosis
    • Adenocarcinoma, moderately differentiated, of the esophagus, EG junction, stage IV, pT3N1(pM1), s/p thoracoscopic esophagectomy, radiotherapy, UFUR, and TS-1, with left mediastinal lymph nodes metastases and suspicious right lung metastases, s/p radiotherapy and status during chemotherapy with brain metastases, s/p radiotherapy.
    • EG junction adenocarcinoma s/p adjuvant CCRT (4860 cGy and UFUR) followed by adjuvant C/T with TS-1, with recurrent adenocarcinoma over middle and lower third trachea, s/p palliative C/T of docetaxel with or without 5-FU /Folinic Acid, s/p R/T with 5760 cGy, in progression, s/p CAL056, with progression of lung metastasis s/p palliative C/T with FOLFOX with brain metastasis s/p whole brain R/T and palliative C/T with FOLFIRI from 2022/08/10
    • Chronic obstructive pulmonary disease, unspecified
    • Gout, unspecified
    • Insomnia, unspecified
  • past history
      1. Gout from 2002 to now
      1. Limping gait from 2006 to now
      1. Benign prostatic hyperplasia from 2010 to now
      1. Herniated Intervertebral Disc from 2010-06-10 to now
      1. Bilateral renal cysts from 2010-06-10 to now
      1. Mitral regurgitation Gr 1 from 2010-06-12 to now
      1. Tricuspid regurgitation Gr 1 from 2010-06-12 to now
      1. Degenerative change of the thoraco-lumbar spine with narrowed intervertebral disc spaces and spurs formation from 2012-04-13 to now
      1. Superimposed bilateral lumbosacral radiculopathy from 2013-08-26 to now
      1. Spondylosis from 2013-09-03 to now
      1. Onychomycosis from 2017 to now
      1. Obstruction sleep apnea from 2017-01-31 to now
      1. Fatty liver from 2017-01-13 to now
      1. Insomnia Gr 1 from 2017-02-07 to now
      1. Productive cough Gr 1 from 2017-06 to now
      1. Chronic obstructive pulmonary disease from 2017-07-14 to now
      1. Chronic allergic rhinitis Gr 1 from 2017-07-14 to 2020-10-21, Gr 2 from 2020-10-22 to now
      1. Gastroesophageal reflux disease Gr 2 from 2018-01-04 to now
      1. Hyperlipidemia Gr 1 from 2018-04-24 to now
      1. Hiatal hernia from 2018-10-16 to 2022-02-06
      1. Superficial gastritis from 2019-12-30 to 2022-02-06
      1. Marginal spurs of multiple vertebral bodies from 2020-07-28 to now
      1. Esophageal shallow ulcers (above ECJ) from 2020-08-05 to now
      1. Hemoptysis, intermittently from 2021-08 to 2021-09-28
      1. Anemia Gr 1 from 2020-08-25 to now
      1. Atherosclerotic change of aortic arch from 2020-10-16 to now
      1. Bilateral carpal tunnel syndrome from 2020-11-17 to now
      1. Retrolordotic curve change of the spine 2020-11-23 to now
      1. Gallbladder stones from 2021-04-13 to now
      1. Reflux laryngitis from 2021-05-13 to now
      1. Mild posterior pericardial effusion from 2021-08-04 to now
      1. Bilateral pleura effusion from 2021-08-04 to now
      1. Platelet count decreased Gr 1 from 2021-12-14 to now
      1. Blood-stinged sputum, intermittently from 2022-01-28 to now      
  • exam finding
    • 2022-09-15 Patho - bronchus biopsy
      • Lung, LB8 endobronchial tumor, bronchoscopic biopsy — adenocarcinoma, consistent with metastatic tumor
      • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
      • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), TTF-1(-), and Napsin A(-). The results are consistent with metastatic adenocarcinoma from esophagogastric junction (cardiac cancer of stomach).
    • 2022-09-15 Bronchoscopy
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was severely narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Movement of the both. vocal cord(s) was normal .
      • Bilateral arytenoid proceww was normal .
      • Trachea whole segment: patent and the mucosa was normal .
      • Main carina: sharp and movable on deep breathing.
      • Bilateral endobronchial trees:
        • Trachea: no tumor recur
        • RML/RLL carina submucosal lesion, without airway mucosal invasion
        • RLL orifice two submucosal lesions, without airway mucosal invasion
        • LB 8 endobronchial tumor with total occlusion
      • Under fluoroscent bronchoscopy:
        • Trachea: no tumor recur
        • RML/RLL carina submucosal lesion, without airway mucosal invasion
        • RLL orifice two submucosal lesions, without airway mucosal invasion
        • LB8 endobronchial tumor with total occlusion, s/p biopsy
      • After RB8 tumor biopsy by 15C biopsy forceps and snare-loop, tumor bleeding was noted, electrocautery with 25W/25W to 35W/35W with heat-probe was done for bleeding control.
    • 2022-08-11 MRI - brain
      • Known a case of EG junction adenocarcinoma s/p CCRT. One enhancing nodular lesion (3.7cm) over right cerebellar lobe, favor a metastatic lesion.
      • Prominent peritumoral edema.
      • The intracranial vessels are normally signal-void.
      • The paranasal sinuses and mastoid air cells are aerated.
      • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
    • 2022-07-08 CT - abdomen, pelvis
      • Findings
        • Prior CT identified several metastases in both lung are noted again. Most of then show stable in size. However, two metastases in RLL and LLL of the lung show increasing in size.
        • Pleura reaction in bilateral posterior basal CP angle.
        • Few calcified gallstones are noted.
        • There are several renal cysts on both kidney and the largest one measuring 3.6 cm in size at left middle pole.
          • In addition, both kidney show mild irregular contour that may be old inflammatory process or normal variation.
        • s/p distal esophagectomy, cardiectomy and esophagogastrostomy.
          • There is no evidence of tumor recurrence.
        • There is no focal abnormality in the liver, biliary system, pancreas, and spleen.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression
        • Prior CT identified several metastases in both lung are noted again. Most of then show stable in size. However, two metastases in RLL and LLL of the lung show increasing in size.
    • 2022-06-16 Bronchial Washing
      • Positive for malignancy
    • 2022-06-15 CXR
      • Bilateral pleural effusions
      • Atherosclerotic change of aortic arch
      • Coarse reticular opacities or Platelike lung atelectasis over Lt Rt lower lung zones
      • Marginal spurs of multiple vertebral bodies.
    • 2022-04-08 CT - abdomen, pelvis
      • Lung metastases show mild increasing in size.
    • 2022-02-07 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis, LA-A (minimal)
        • Postoperative status of partial esophagectomy and gastric tube reconstruction.
        • Much food residue retention in esophagus and stomach
        • Incomplete study
      • Suggestion
        • OPD follow-up
    • 2022-01-28 CT - abdomen, pelvis
      • Lung metastases show mild increasing in size.
    • 2022-01-06 Bronchoscopy
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was severely narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Movement of the both. vocal cord(s) was / werenormal .
      • Bilateral arytenoid proceww was normal .
      • Trachea whole segment: patent and the mucosa was normal.
      • Main carina: sharp and movable on deep breathing.
      • Bilateral endobronchial trees:
        • RML bronchus swelling and hyperremic, easy touch bleeding.
        • No visible endobronchial lesion
    • 2021-11-22 CT - lung
      • bilateral lung and mediastinal metastases, slightly in progression as compared with previous CT study on 20210804
    • 2021-08-04 CT - lung
      • consistent with bilateral lung and mediastinal metastases, in progression as compared with previous CT study on 20210719
    • 2021-07-19 CT - abdomen
      • S/P gastric operation.
      • Small nodules at right lung suspected metastases.
    • 2021-04-13 CT - abdomen
        1. Gastric cancer s/p partial gastrectomy. Suggest follow up.
        1. Bilateral renal cysts.
        1. GB stones.
        1. Old fractures at bilateral ribs.
        1. Bilateral basal lung atelectasis.
    • 2021-02-24 ECG
      • Sinus tachycardia
      • Possible Inferior infarct, age undetermined
    • 2020-11-06 CT -lung
      • Gastric cancer s/p partial gastrectomy.
      • Right lower lobe and left lower lobe intrafissural nodule. Decreased in size.
      • Right upper lobe tiny nodule. Stable.
    • 2020-09-03 Patho - trancheal biopsy
      • Lung, side ?, bronchoscopic biopsy — adenocarcinoma, poorly differentiated, consistent with recurrence
    • 2020-08-07 Tc-99m MDP whole body bone scan with SPECT
        1. Prominently increased activity in the L3-5 spines and L5-sacrum junction. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
        1. Mildly increased activity in the lower C-spine, middle and lower T-spines. Degenerative change is more likely.
        1. Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, wrists and knees, compatible with benign joint lesions.
    • 2020-08-05 Patho - trancheal biopsy
      • Lung, ? side, bronchoscopic biopsy — adenocarcinoma, moderately differentiated, in favor of recurrence
      • Sections show bronchail mucosa with neoplastic glandular cells infiltrating in submucosa.
      • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), TTF-1(-), and Napsin A(-). The results are in favor of recurrent tumor.
      • The HER2/NEU In-Situ Hybridization Test report from Taipei Institute of Pathology is NEGATIVE. There is NO amplication of HER2 detected.
    • 2020-08-04 Esophagography
      • s/p distal esophagectomy with esophagogastrostomy
      • High grade gastroesophageal reflex
    • 2020-07-28 CT - lung
      • recurrent gastric cancer as metastatic left mediastinal LAP and suspect two metastatic Rt lung nodules.
    • 2019-08-01 Impedance Audiometry
      • Reliabilty Fair
      • PTA
        • R’t : 41 dB HL
        • L’t : 41 dB HL
        • Bil normal to severe SNHL
      • Tymp
        • Bil Type B
      • ART
        • Bil absent.
    • 2019-04-01 CT - abdomen
      • s/p distal esophagectomy and cardiectomy with esophagogastrostomy.
      • There is no evidence of tumor recurrence.
  • surgical operation
    • 2016-12-12
      • VATS with subtotal esophagectomy, cardiectomy and jejunostomy
  • radiotherapy
    • 2020-08-14 ~ 2020-09-28 - 5760 cGY/32Fx
    • 2017-05-18 ~ 2017-06-27 - CCRT with 4860 cGy/27 fractions
  • chemoimmunotherapy
    • 2022-10-06 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 4800mg 48hr
    • 2022-09-21 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 4970mg 48hr
    • 2022-09-07 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-08-24 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-08-10 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-07-20 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-07-06 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-06-01 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-05-18 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-05-04 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-04-20 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-03-14 - investigational CAL056
    • 2022-02-15 - investigational CAL056
    • 2022-01-12 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5000mg 48hr
    • 2021-12-29 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-12-15 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2000mg/m2 4300mg 48hr
    • 2021-11-17 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2000mg/m2 4300mg 48hr
    • 2021-11-03 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-10-20 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-10-06 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-09-22 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-09-08 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5000mg 48hr
    • 2021-08-25 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2400mg/m2 5000mg 48hr
    • 2021-08-11 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-07-28 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-07-14 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-06-30 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-06-16 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-06-02 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-05-19 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-05-05 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-04-21 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-04-07 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-03-24 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-03-09 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-02-17 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-02-03 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-01-21 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2020-12-25 - docetaxel 25mg/m2 54mg 1hr
    • 2020-11-27 - docetaxel 25mg/m2 54mg 1hr
    • 2020-11-20 - docetaxel 25mg/m2 54mg 1hr
    • 2020-11-05 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-30 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-16 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-08 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-02 - docetaxel 25mg/m2 54mg 1hr
    • 2020-09-17 - docetaxel 25mg/m2 54mg 1hr
    • 2020-09-10 - docetaxel 25mg/m2 54mg 1hr
    • 2020-08-25 - docetaxel 25mg/m2 54mg 1hr
    • 2020-08-19 - docetaxel 25mg/m2 54mg 1hr
    • 2017-08-22 ~ 2018-05-07 - TS-1 (25 mg bid of Tegafur/Gimeracil/Oteracil, 25 mg/7.25 mg/24.5 mg)
    • 2017-05-18 ~ 2017-06-27 - UFUR (2 capsules bid of Tegafur/Uracil, 100 mg/224 mg), CCRT

==========

2022-10-14

  • There is an underlying condition of COPD in this patient. The CXR taken on 2022-10-13 showed ground glass opacities in both lungs. His symptoms of SOB lasted for a week and he has been treated with tapimycin (piperacillin + tazobactam) since 2022-10-13.

2022-10-07

  • In the last two months, weight loss has exceeded 10 kilograms (86.3kg 2022-10-06 <- 99.1kg 2022-08-03) (due to reduced intake or other factor?)
  • The underlying conditions of COPD, gout, and insomnia are managed with appropriate medication and remain stable.

2022-08-11

  • As indicated by CT findings of mildly growing lung metastases, the lab tumor markers CEA and CA199 have slowly trended up since March 2022.
    • CEA
      • 2022-07-19 5.77 ng/mL
      • 2022-06-14 4.91 ng/mL
      • 2022-05-17 4.13 ng/mL
      • 2022-04-12 3.44 ng/mL
      • 2022-03-14 2.81 ng/mL
    • CA199
      • 2022-07-19 38.82 U/mL
      • 2022-06-14 29.36 U/mL
      • 2022-05-17 23.62 U/mL
      • 2022-04-12 12.43 U/mL
      • 2022-03-14 9.06 U/mL
  • Curam 1000mg/tab (amoxicillin 875mg + clavulanic acid 125mg) 1# PO BID has been prescribed since 2022-06-21. Either amoxicillin-clavulanate or a respiratory fluoroquinolone (ie, levofloxacin or moxifloxacin) are recommended for exacerbations of COPD patients who have risk factors for poor outcomes (but no increased risk for Pseudomonas infection). Elderly patients might be at increased risk of developing amoxicillin-clavulanate-induced jaundice. Prolonged treatment might increase the risk of hepatotoxicity.
  • There is a history of gout, mitral regurgitation, and tricuspid regurgitation in the patient. A recent large RCT showed that in patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to rates of adverse cardiovascular events. Allcause mortality and cardiovascular mortality were higher with febuxostat than with allopurinol. ( https://www.nejm.org/doi/full/10.1056/NEJMoa1710895 ). Febuxostat is currently prescribed as equivalent daily dose of 20 mg (80 mg 0.5# QOD), which should reduce the risk of cardiovascular events.

700928671

221014

  • lab data

    • 2021-12-14 Anti-HBs 7.30 mIU/mL
    • 2021-12-13 HBsAg Nonreactive
    • 2021-12-13 HBsAg (Value) 0.45 S/CO
    • 2021-12-13 HBeAg Nonreactive
    • 2021-12-13 HBeAg(Value) 0.326 S/CO
    • 2021-12-13 Anti-HBe Reactive S/CO
    • 2021-12-13 Anti-HBe Ratio 0.66 S/CO
    • 2021-12-13 Anti-HBc Reactive
    • 2021-12-13 Anti-HBc-Value 5.36 S/CO
    • 2021-12-13 Anti-HBc IgM Nonreactive
    • 2021-12-13 Anti-HBc IgM Value 0.12 S/CO
  • exam findings

    • 2022-10-12 CXR
      • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
      • small Rt hemithorax, elevation of hemidiaphgram and superior convexity of major fissure due to post operative change of RUL lobectomy
      • Subcutaneous emphysema in Rt chest wall neck in regression as compared with the previous image
      • no right pneumothorax
    • 2022-09-26 Patho - lung total/lobe/segmental
      • PATHOLOGIC DIAGNOSIS:
        • Lung, right, upper lobe, lobectomy —- pleomorphic carcinoma with squamous cell carcinoma
        • Lymph node, lobar, lymphadenectomy —- pleomorphic carcinoma, metastatic (3/4)
        • Lymph node, right, group No.2+4, lymphadenectomy —- pleomorphic carcinoma, metastatic (6/11)
        • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, right, group No.10, lymphadenectomy —- Negative for malignancy (0/2)
        • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/2)
        • Lymph node, right, group No.12, lymphadenectomy —- pleomorphic carcinoma, metastatic (3/3)
        • AJCC 8th edition pTNM Pathology stage: pStage IVA, pT4N2(if cM1a(by CT finding)) or pStage IIIB, pT4N2(if cM0)
      • MACROSCOPIC EXAMINATION:
        • Specimen:
          • Lung, size: 12 x 7 x 4.5 cm with a piece of parietal pleura, measruing 3.3 x 3.0 cm
          • Lymph nodes, 6 bottles, group 2+4, 7, 9, 10, 11, 12; maximal size: 2.8 x 1.9 cm
        • Tumor Site: Periphery
        • Tumor Size: Multiple (Number: several), Maximal one: 8.2 x 5.5 x 5.0 cm
        • Gross tumor patterns: poorly defined, Pleural retraction with invasion to parietal pleura
        • Tissue for sections:
          • A1: bronchial and vascular resection margins; A2: parenchymal resection margin; A3: lymph node, lobar; A4: lung with satellite tumor nodules; A5: bronchus; A6-7: tumor with parietal pleura; A8-10: tumor; B1-4: lymph node, group 2+4; C: lymph node, group 7; D: lymph node, group 9; E: lymph node, group 10; F: lymph node, group 11; G: lymph node, group 12.
      • Microscopic Description
        • Tumor Focality: Separate tumor nodules of same histopathologic type (intrapulmonary metastases) in same lobe
        • Histologic Type (select all that apply): Pleomorphic carcinoma with squamous cell carcinoma; The immunohistochemical stains reveal CK7(-), CK20(-), CK5/6(+), p40(+), TTF-1(-), Napsin A(-), CD56(-).
        • Histologic Grade: G3: Poorly differentiated
        • Spread Through Air Spaces (STAS): Present
        • Visceral Pleura Invasion: Present (PL2) with invasion to parietal pleura
        • Lymphovascular Invasion (select all that apply): Present, Lymphatic
        • Direct Invasion of Adjacent Structures (select all that apply): Adjacent structures present and involved, Parietal pleura
        • Margins (select all that apply):All margins are uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin (centimeters): 0.05 cm
          • Specify closest margin: Parietal pleura
          • Bronchial resection margin: 2.5 cm
        • Treatment Effect: No known presurgical therapy
        • Regional Lymph Nodes: lobar: 3/4; group 2+4: 6/11; group 7: 0/1; group 9: 0/1; group 10: 0/2; group 11: 0/2; group 12: 3/3.
        • Extranodal Extension: Present
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT4: Tumor >7 cm in greatest dimension;
          • Regional Lymph Nodes (pN): pN2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM1a (by CT finding)
        • Additional Pathologic Findings (select all that apply): None identified
    • 2022-09-20 Whole body PET scan
      • Glucose hypermetabolism in a large focal area in the upper lobe of right lung, compatible with primary lung malignancy.
      • Glucose hypermetabolism in a smal focal area in the upper lobe of right lung, compatible with a metastatic lesion.
      • Glucose hypermetabolism in the right pulmonary hilar region and in some right lower paratracheal lymph nodes. Metastatic lymph nodes may show this picture.
      • Glucose hypermetabolism in the right adrenal gland and in multiple bones as mentioned above. Adrenal metastasis and multiple bone metastases may show this picture.
      • Mild glucose hypermetabolism in the lower portion of the esophagus and in a right supraclavicular lymph node. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • 2022-09-14 CT - lung/mediastinum/pleura
      • Imaging Report Form for Lung Carcinoma
      • T4N2M1a AJCC8.0
    • 2022-09-01 MRI - nasopharynx
      • C/W oral cancer s/p operation without evidence of recurrence. Right upper lung mass (67 mm), suspected infection or metastasis.
    • 2022-03-03 Patho - oral cancer (wide excision + lymph node)
      • Left buccal mucosa, partial lips and extraoral facial skin near lip conner, s/p induction chemotherapy wide excision (S2022-3441H) with frozen section (F2022-85) — Residual verrucous carcinoma.
      • Lymph node, left neck, dissection — Free
      • ypT2 ypN0 (if cM0); ypStage: II, at least.
    • 2022-03-01 MRI - nasopharynx
      • Markely regressed left buccal, oral commissure, upper lip tumors. Regressed left level I LAP.
      • Tumor, left buccal mucosa, incisoinal biopsy — Compatible with squamous cell carcinoma and ulcer
      • Microscopically, the sections show a picture of ulcer with dense inflammation and atypical squamous epithelium with hyperkeratosis, occasional mitoses and few isolated nests or buds in dense inflammatory stroma. According to clinical (7 cm big mass), MRI (T4a) and histopathologic findings, it is compatible with squamous cell carcinoma, microinvasive. However, more advanced invasion can not excluded due to limited specimen.
      • Immunohistochemistry shows CK5/6(+), CK(+, weakly), P16(-), P53(+, focal) and P63(+) for tumor.
    • 2021-12-10 Tc-99m MDP whole body bone scan
      • Increased activity in the middle C-spine, L3 and L5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2021-12-10 SONO - abdomen
      • Diagnosis
        • Fatty liver, mild
        • Left renal cyst
      • Suggestion
        • Please correlate with other image study and clinical condition
        • Regular f/u
    • 2021-12-09 MRI - nasopharynx
      • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage): T:4a(T_value) N:1(N_value) M:0(M_value) STAGE:IVA(Stage_value)
    • 2021-11-30 Patho - gingival/oral mucosa biopsy
      • Oral cavity, left buccal mucosa to lip commissure, incisional biopsy — Verrucous carcinoma
      • Microscopically, it shows verrucous carcinoma composed of club-shaped papillae and blunt intrastromal invagination of well-differentiated squamous neoplasm with inflammatory infiltrate at the submucosa. The tumor invades the stroma with a pushing.
      • IHC stain — p16(-)
  • consultation

    • 2022-03-18 Radiation Oncology
      • A
        • A: Squamous cell carcinoma and verrucous carcinoma of the left lip commissure to left buccal area, stage cT4aN1M0 (IVA), s/p induction chemotherapy and operation (Modified radical neck dissection of left side. Wide excision of the malignant tumor at the left buccal mucosa, partial lips and extraoral facial skin near lip conner. Complicated tooth extraction of 7 teeth. Alvealoplasty of left and right maxilla. Left ALT free flap reconstruction. ALT donor site closure using fasciocutaneous rotational flap), stage ypT2N0(cM0).
        • P: According to HN tumor board (2022-03-18) conclusion: postoperative CCRT is indicated for this patient with the following indicators: skin sparing conservative surgery with cosmetic and function preservation of his left lip commissure area.
          • Goal: curative
          • Treatment target and volume: left lip commissure, buccal tumor bed to bilateral neck area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 5000cGy/25 fractions of the left lip commissure, buccal tumor bed to bilateral neck, and 6600cGy/33 fractions of the left lip commissure and buccal tumor bed.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-03-24.
  • SOP

    • 2022-10-11 Radiation Oncology
      • A:
        • Squamous cell carcinoma and verrucous carcinoma of the left lip commissure to left buccal area, stage cT4aN1M0 (IVA), s/p induction chemotherapy and operation (Modified radical neck dissection of left side. Wide excision of the malignant tumor at the left buccal mucosa, partial lips and extraoral facial skin near lip conner. Complicated tooth extraction of 7 teeth. Alvealoplasty of left and right maxilla. Left ALT free flap reconstruction. ALT donor site closure using fasciocutaneous rotational flap), stage ypT2N0(cM0), s/p CCRT.
        • Pleomorphic carcinoma with squamous cell carcinoma of the lung, RUL, stage AJCC 8th edition pTNM. Pathology stage: pStage IVA, pT4N2(cM1b), s/p VATS, RUL lobectomy + RLND.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: very close surgical margin
        • Goal: palliation
        • Treatment target and volume: primary lung tumor bed and regional lymphatic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5400cGy/30 fractions of the primary lung tumor bed and regional lymphatic area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sons. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-10-19.
  • radiotherapy

  • chemoimmunotherapy

    • 2022-05-16 - cisplatin 40mg/m2 70mg 2hr
    • 2022-05-04 - cisplatin 40mg/m2 70mg 2hr
    • 2022-04-21 - cisplatin 40mg/m2 70mg 2hr
    • 2022-04-13 - cisplatin 40mg/m2 70mg 2hr
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 170mg in fluorouracil 900mg/m2 1700mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)

[assessment]

  • Pleomorphic carcinoma is a poorly differentiated non-small cell carcinoma that contains at least 10% spindle and/or giant cells or a carcinoma consisting only of spindle and giant cells.
  • There are no related molecular testing results available in HIS5 that might be considered, including: EGFR mutations, ALK, KRAS, ROS1, BRAF, NTRK1/2/3, METex14 skipping, RET, ERBB2 (HER2), PD-L1.
  • Hypercalcaemia (2022-10-14 3.86 mg/dL) and hyperuricemia (2022-10-14 8.7 mg/dL) are treated with allopurinol and zoledronic acid, respectively.

701394404

221014

{Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16}

  • last discharge diagnosis
    • 1: Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16
    • 2: Postive of anti-HBc
    • 3: Anemia
    • 4: Hypertension
    • 5: Hyperlipidemia
    • 6: Hypoalbuminemia
  • lab data
    • albumin
      • 2022-07-08 2.9 g/dL
      • 2022-06-21 2.8 g/dL
  • exam finding
    • 2022-10-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (34 - 14) / 34 = 58.82%
        • M-mode (Teichholz) = 58
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR, trivial AR and mild TR and trivial PR
      • Mild to moderate pulmonary hypertension
      • Preserved RV systolic function
      • Tachycardia with E/A fusion at the exam.
    • 2022-10-12 KUB
      • marginal spurs of multiple vertebral bodies due to spondylosis.
      • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
      • Abdominal ascites
      • interrupted lower body of gastric air column and scanty colonic air
      • Normal shape and size of kidneys and spleen.
      • Normal appearance of psoas shadows
    • 2022-10-12 CXR
      • Thoracic aortic arch calcified atheriosclerotic plaque
      • Fullness and increased density of Rt infrhilum hila may be due to lymphadenopathy
      • Normal heart size
      • Costophrenic angles are preserved
    • 2022-10-12 ECG
      • Sinus tachycardia
      • Low voltage QRS
      • Borderline ECG
    • 2022-09-16 CT - abdomen
      • Findings:
        • There are several newly-developed poor enhancing masses on both hepatic lobes that are c/w liver metastases.
          • The largest one measuring 4.3 cm in S3.
        • There is mild ascites and soft tissue nodules in the omentum that may be carcinomatosis.
        • Prior CT identified gastric wall thickening is noted again, mild increasing in wall thickness.
        • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space are noted again, mild increasing in size.
        • There is no focal lesion in both lung.
          • There are several enlarged nodes in paratracheal space.
        • Few gallstones are noted and the largest one 1.6 cm.
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Multiple liver metastases.
        • Carcinomatosis is highly suspected.
    • 2022-06-16 Body fluid cytology - ascites
      • 20 cc dark-brown turbid ascites — Atypia
      • The smears show lymphocytes, reactive mesothelial cells and few atypical cells show enlarged and hypochromatic nuclei with degenerative quality. Follow up.
    • 2022-06-15 Upper GI series
      • The contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
      • Normal contour and mucosal pattern of the esophagus. S/P NG tube indwelling.
      • Distention of stomach suspected outlet obstruction.
    • 2022-06-13 Patho - stomach biopsy
      • Stomach, antrum, biopsy — Adenocarcinoma.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
    • 2022-06-11 CT - abdomen, pelvis
      • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T3N3M1, stage IVB
    • 2022-06-11 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Highly suspected gastric cancer, Borrmann classification type III, with suspected gastric outlet obstruction, s/p biopsy.
        • Reflux esophagitis LA Classification grade D
        • Incomplete study due to much coffee ground content and food retention in stomach and gastric outlet obstruction
      • Suggestion
        • PPI Q12H IV
    • 2022-06-10 ECG
      • Sinus tachycardia
      • Nonspecific ST abnormality
      • Abnormal ECG
  • consultation
    • 2022-06-13 General and Gastrointestinal Surgery
      • Q
        • This is a 67-year-old male with hx of HTN.
        • This time, he suffered from vomiting with black vomitus, dizziness, and tarry stool for 2 days. Body weight loss ~15kg in 1-2 month was noted. He was brought to our ER for help. At ER, the vital signs were generally normal with tachycardia (HR 129bpm) with BP 117/58mmHg. Lab study found Hb: 5.0g/dL, with stool OB: 2+, emergent blood transfuion with LPRBC 4U was given, and anemia improved (Hb: 5.0 -> 8.4 g/dL with f/u Hb: 6.9 -> 7.6). Abdome CT showed gastric cancer with gastric outlet obstruction cstage: T3 N3b M1 (lack of detailed description of metastasis).
        • Under the impression of Suspect gastric cancer, so he was admitted for urther evaluation and management.
        • We need your expertise for further evaluation for the patient’s condition of gastric cancer, and outlet obstruction, and future feeding method.
      • A
        • S: A 67-year-old male with hx of HTN. This time, he suffered from vomiting with black vomitus, dizziness, and tarry stool for 2 days. Body weight loss ~15kg in 1-2 month was noted. He was brought to our ER for help. At ER, the vital signs were generally normal with tachycardia (HR 129bpm) with BP 117/58mmHg. Lab study found Hb: 5.0g/dL, with stool OB: 2+, emergent blood transfuion with LPRBC 4U was given, and anemia improved (Hb: 5.0–>8.4 g/dL with f/u Hb: 6.9->7.6). Abdome CT showed gastric cancer with gastric outlet obstruction cstage: T3 N3b M1(lack of detailed description of metastasis). Surgical evaluation is consulted.
        • O: vital signs: stable, no fever
          • abdomen: soft, ovoid, decrease bowel sound, mild epigastric pain, no Murphy’s sign
          • lab data: see chart
        • A: gastric cancer with gastric outlet obstruction cstage: T3 N3b M1, stage IV
        • P: Suggest neoadjuvant chemotherapy for down staging first.
          • If gastric outlet obstruction related poor oral intake and malnutrition is noted, laparoscopic gastrojejunostomy may be considered.
    • 2022-06-16 Hemato-Oncology
      • Q
        • This is a 67 year-old male who has the history of hypertension with medication control. This time, he suffered from vomiting with black vomitus, dizziness, and Tarry stool for 2 days. Body weight loss ~15kg in 1-2 month, so he was brought to our ER for help. Under the impression of gastric cancer, he was transfer to GS for surgery of gastrojejunostomy on 2022/06/16. We need your help for neoadjuvant chemotherapy. Thank you so much!!
      • Q
        • Impression:
          • Suspect gastric cancer with gastric outlet obstruction cstage: T3 N3b M1, stage IV
        • Suggestion
            1. Pending pathology, if confirm gastric cancer, we will discuss with patient about neoadjuvant chemotherapy for down staging.
            1. Check anti Hbc, HbsAg, Anti HCV
        • s/p gastrojejunostomy on 2022/06/16.
        • Medical advice:
          • It will be possible to be cured only in the patient whose gastric cancer is amenable to total surgical resection (R0 resection). The local advanced gastric CA wt gastric outlet obstruction of this pt is deemed not operably subjected to total surgical resection.
          • Pre-Op neoadjuvant C/T is indicated.
            • Pre-Op neoadjuvant C/T regimen may be: Oxaliplatin / HDFL or 5-FU / LV / Oxaliplatin / Docetaxel ( FLOT ) IV Q2W x 3~4 cycles beofore / after Op.
          • If gastric tumor bleeding persists, may consider R/T to gastric tumor to cease bleeding.
  • surgical operation
    • 2022-06-16
      • Surgery
          1. Laparoscopic gastrojejunostomy
          1. Port-A insertion, L’t after L’t cephalic vein exploration        
        • Post-OP Dx: gastric antrum Ca, cT3N3M1, stage IV, ECOG 1    
      • Finding
          1. We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
          1. Hypertorphy and distension of stomach.
          1. No visible peritoneal wall tumor and enlarged lymph node was noted. We collect ascites for cytology.
          1. Gastric juice 2750 ml was decompressed.
  • chemoimmunotherapy
    • 2022-07-08 ~ undergoing - FOLFOX

==========

2022-10-14

  • 2022-10-13 2D transthoracic echocardiography showed adequate LV systolic function with normal resting wall motion and preserved RV systolic function.
  • It is possible that the rising levels of hs-Troponin I (366.4 <- 226.8 <- 134.4) are related to sepsis. The infection is currently being managed with tapimycin (piperacillin + tazobactam).

2022-07-11

  • This patient is taking two antiplatelet agents: aspirin, cilostazol (antiplatelet agent; phosphodiesterase-3 enzyme inhibitor; vasodilator); four antihypertensives: amlodipine (antianginal agent; antihypertensive; calcium channel blocker), indapamide (thiazide diurectic), spironolactone (antihypertensive; potassium sparing diurectic; mineralocorticoid (aldosterone) receptor antagonists), ramipril (angiotensin-converting enzyme (ACE) inhibitor; antihypertensive).
  • It was reported that salicylates and/or thiazides could enhance the nephrotoxic effect of angiotensin-converting enzyme inhibitors, and potassium-sparing diuretics may enhance the hyperkalemic effect of angiotensin-converting enzyme inhibitors. According to lab data on 2022-07-08, renal function and serum potassium were normal.
  • Since the afternoon of 2022-07-09, blood pressure readings have returned to normal, and no tachycardia has been observed since 2022-07-10. TPR and BP are stable currently.
  • Crestor (rosuvastatin calcium 10mg) QD might be an option if hyperlipidemia is still a medical problem.

700410422

221012

  • exam findings
    • 2022-09-13 CXR
      • distorted and small left hilum, small left hemithorax with decreased vascular markings, and Lt shift of heart due to LLL lobectomy
      • Lt pleural effusion/thickening with loculation, stationary
    • 2022-07-21 MRI - brain
      • Known a case of lung. No metastatic lesion of brain parenchyma.
    • 2022-07-19 CT - chest
      • post op change in left hemithorax. decreased volume of left pleural effusion compared with CT on 20220309.
      • mild emphysema in left upper lung and RUL.
      • no mediastinal or hilar enlarged lymph nodes.
      • no new lung nodule or mass.
    • 2022-04-11 Whole body PET scan
      • Glucose hypermetabolism in the left lower and right upper lungs, cancer s/p treatment with chronic inflammation may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • Increased FDG uptake in the left aspect of the maxilla, probably dental and/or gum problems.
      • Increased FDG uptake/accumulation in the colon and bilateral ureters, physiological FDG uptake/accumulation is more likely.
      • No prominent abnormal focal FDG uptake is noted elsewhere.
    • 2022-03-09 CT - chest
      • post op change in left hemithorax. increase in volume of moderate left pleural effusion compared with CT on 20211208
      • mild emphysema in left upper lung and RUL.
      • no mediastinal or hilar enlarged lymph nodes.
      • no new lung nodule or mass.
    • 2021-12-10 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20210728, no prominent change is noted.
      • Suspected benign lesions in the maxilla, mandible, some L-spines, bilateral shoulders, S-I joints, hips, and knees.
    • 2021-12-09 MRI - brain
      • No evident brain metastasis.
    • 2022-03-09 CT - chest
      • post op change in left hemithorax. stationary of moderate left pleural effusion compared with CT on 20210916
      • mild emphysema in left upper lung and RUL.
      • no mediastinal or hilar enlarged lymph nodes.
      • no new lung nodule or mass.
    • 2021-09-16 CT - chest
      • Left pleural effusion.
      • s/p left lower lobe lobectomy.
    • 2021-07-28 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the maxilla, mandible, L-spine, bilateral shoulders, S-I joints, hips, and knees.
    • 2021-06-23 CT - chest
      • post op change in left hemithorax. slighlty increase in volume of left pleural effusion compared with CT on 20210304.
      • mild emphysema in left upper lung and RUL.
      • suspect mild small airways disease in RLL.
      • no new lung nodule or mass.
    • 2021-03-04 CT - chest
      • Ground glass pacthes at left lung with left pleural effusion. Recent pneumonia is favored.
    • 2021-03-03 MRI - brain
      • no evidence of metastatic brain tumors
    • 2020-11-12 Whole body PET scan
      • Mild glucose hypermetabolism in the left lower lung field. Post-operative inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • Increased FDG uptake in the region about the left aspect of maxilla. The nature is to be determined (some kind of dental and/or gum problem? other nature?). Please also correlate with other clinical findings for further evaluation.
      • Increased FDG uptake/accumulation in bilateral vocal cords and both kidneys. Physiological FDG uptake/accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2020-11-11 MRI - brain
      • focal SI change in the splenium of the corpus callosum. Nature?
    • 2020-11-10 CT - chest
      • post op change in left hemithorax. increase in volume of left
      • pleural effusion compared with CT on 20200818.
      • mild emphysema in left upper lung and RUL.
      • suspect mild small airways disease in RLL.
      • no new lung nodule or mass.
    • 2020-08-18 CT - chest
      • post op change in left hemithorax.
      • mild emphysema in left upper lung and RUL.
      • no new lung nodule or mass.
    • 2020-06-03 Patho - lung total/lobe/segmental
      • PATHOLOGIC DIAGNOSIS:
        • Lung, left, lower lobe, lobectomy —- Adenocarcinoma, moderately differentiated, s/p CCRT and Immuotherapy
        • Lymph node, lobar, lymphadenectomy —- Negative for malignancy (0/1)
        • Soft tissue, group No.7 lymph node, lymphadenectomy —- Negative for malignancy (0/0)
        • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, group No.10, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, group No.12, lymphadenectomy —- Negative for malignancy (0/1)
        • AJCC 8th edition pTNM Pathology stage: ypStage IB, ypT2aN0(if cM0)
      • MACROSCOPIC EXAMINATION:
        • Specimen:
          • Lung, size: 13.5 x 7.4 x 2.7 cm; 89.9 gm
          • Lymph nodes, 4 bottles, group 7, 9, 10, and 12; maximal size: 0.8 x 0.3 x 0.3 cm
        • Tumor Site: Periphery
        • Tumor Size: Solitary: 2.1 x 2.0 x 1.8 cm
        • Gross tumor patterns: poorly defined, Pleural retraction
      • Microscopic Description
        • Tumor Focality: Single tumor
        • Histologic Type (select all that apply): Invasive adenocarcinoma, acinar predominant (60 %);
          • The immunohistochemical stains reveal CK(+) and TTF-1(+).
          • Other subtypes present (specify subtype(s), may also include percentages): lepidic: 40%
        • Histologic Grade: G2: Moderately differentiated
        • Spread Through Air Spaces (STAS): Not identified
        • Visceral Pleura Invasion: Present (PL2)
        • Lymphovascular Invasion (select all that apply): Present, Lymphatic
        • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
        • Treatment Effect: Greater than 10% residual viable tumor
        • Regional Lymph Nodes: lobar: 0/1; group 7: 0/0; group 9: 0/1; group 10: 0/1; group 12: 0/1
        • Extranodal Extension: Not identified
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) : y (posttreatment)
            • Primary Tumor (pT): pT2a: Invades visceral pleura (PL2);
            • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
        • Additional Pathologic Findings (select all that apply): None identified
    • 2018-05-23 Surgical pathology Level IV
      • Clinical diagnosis
        • Chronic airway obstruction (COPD), NEC;
      • Pathological diagnosis
        • Soft tissue, neck, needle biopsy — adenocarcinoma, moderately differentiated, metastatic, consistent with lung origin
      • Specimen submitted in formalin consists of 2 strips of tan, irregular tissue measuring up to 1.6 x 0.1 x 0.1 cm. All for section in one cassette.
      • Sections show solid tumor nests, with focal glandular pattern, infiltrating in a fibrotic stroma. No lymphoid tissue is seen.
        • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for metastatic lung adenocarcinoma.
    • 2018-05-18 Surgical pathology Level IV
      • Indication: Localized swelling, mass and lump, neck; Fracture of frontal skull and SAH; Unspecified open wound of scalp, initial encounter; Hypovolemic shock; Unspecified open wound, right foot, initial encounter; Screening for malignant neoplasms of oral cavity; Enlargement of lymph nodes; Swelling, mass,or lump in head and neck;
      • Pathological Diagnosis: Lymph node, left lower neck, sono-guide biopsy — Metastatic adenocarcinoma, pulmonary origin
      • The specimen submitted consisted of 1 strip of lymph node tissue measuring 1.2 cm in length, fixed in formalin. Grossly, it was grey in color and soft in consistence. All embedded for sections in one cassette.
      • Microscopically, the section shows a picture of metastatic adenocarcinoma of the lymph node tissue characterized by nest or tubular-arranged tumor cells infiltrated in parenchyma.
      • Immunohistochemical stains of CK(+), TTF-1(+); P40(-), Napsin-A(+) and CD56(-) for tumor cells.
        • According to clinical information and above histopathologic findings, it is consistent with metastatic adenocarcinoma of pulmonary origin. Clinical correlation is advised.
    • 2018-05-18 Neck sonography
      • Findings: Multiple LNs in bilateral neck, with size up to 1.37 cm in length at right and 3.3 cm at left.
      • Imp: Multiple bilateral neck LNs.
  • SOP
    • 2018-07-18
      • 20180718 Apply Crizotinib for ALK inhibitor 1st line, maybe wait to August admission for C/T with Alimta, Kytruda first, CCRT
      • A case of Lung cancer, adenocarcinoma, T2aN3M0, stage IIIB, with left supraclavicular LAPs metastasis, ECOG 1, T2a: LLL mass N3: bilateral mediastinal and left supraclavicular LAPs M0: no definite brain, lung to lung metasatsis
      • EGFR mutation: L858R (-), exon 19 (-), PD-L1: 5%, ALK(+)
      • cough with sputum, chest tightness, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), body weight loss(+), poor appetite(+) Past history: Family history of malignancy(-) Smoking(+), 1ppd for 20 yrs, Allergic history:(-) Traveling history:(-) PFT: Mild restriction without Significant response to Bronchodilator
      • C1 Keytruda (2mg/kg) 100mg IVF on 20180620, C1 Alimta (500mg/m2) 800mg on 20180621, admission for 20180712 for Alimta, may add Keytruda or Crizotinib
  • radiotherapy
    • 2018-07-02 ~ 2018-07-30 - 5000cGy/20 fractions (14 MV photon) to LLL tumor, mediastinal & SCF LAPs.
  • chemoimmunotherapy
    • 2022-09-14 - Cyramza (ramucirumab) 500mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-08-17 - Cyramza (ramucirumab) 500mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-07-20 - Cyramza (ramucirumab) 500mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-05-05 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-04-06 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-03-08 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-02-17 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2022-01-04 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-12-07 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-11-15 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-10-12 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-09-15 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-08-18 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-07-27 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-06-23 - Cyramza (ramucirumab) 400mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-04-26 - Cyramza (ramucirumab) 200mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-03-29 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Opdivo (nivolumab) 100mg 1hr D2
    • 2021-03-02 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2021-02-02 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2021-01-11 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-12-09 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-11-10 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-10-13 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-09-15 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-08-18 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-07-21 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-06-22 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-05-25 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-04-27 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-03-31 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-03-05 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2020-02-12 - Cyramza (ramucirumab) 7.5mg/kg 200mg 1.5hr D1 + Keytruda (pembrolizumab) 2mg/kg 100mg 30min D2
    • 2019-09-06 ~ ?? - Cyramza (ramucirumab) 400mg
    • 2018-06-21 - Alimta (pemetrexed) 500mg/m2 800mg
    • 2018-06-20 ~ 2019-08-15 - Keytruda (pembrolizumab) 100mg (C1-13)
    • 2021-11-15 ~ 2022-07-25 - Alunbrig (brigatinib) 90mg/tap 1# QD
    • 2020-09-14 ~ 2021-10-13 - Zykadia (ceritinib) 150mg/cap 1# QD
    • 2019-08-28 ~ undergoing - Alecensa (alectinib) 150mg/cap 4# BIDCC
    • 2018-08-29 ~ 2019-07-25 - Xalkori (crizotinib) 250mg/cap 1# BID
      • alectinib, brigatinib, ceritinib, crizotinib are for ALK rearrangement

701116474

221012

[exam findings]

  • 2023-05-31 ECG
    • Sinus bradycardia with 1st degree A-V block
  • 2023-05-31 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Enlargement of cardiac silhouette.
    • Linear opacity projecting at right lower lung show stationary.
  • 2023-04-07 CT - abdomen
    • History: 65 y/o male with Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, MIPI: 6.4 points.
    • Indication: FU mantle cell lymphoma over both side of diaphragm
    • Findings: Comparison prior CT dated 2023/01/17.
      • Prior CT identified several enlarged nodes in bilateral inguinal area noted again, stationary.
      • Prior CT identified infiltrative soft tissue lesions (confluent enlarged nodes) in the retroperitoneum around the aortocaval region, encasement of SMA/SMV and celiac trunk are noted again, stationary that is c/w Mantle cell lymphoma S/P C/T with stable disease.
      • There is minimal pleura reaction in Rt CP angle.
      • There are several renal cysts on left kidney and the largest one measuring 2.3 cm in size at left upper pole.
    • Impression:
      • Mantle cell lymphoma S/P C/T show stable disease.
  • 2023-01-17 CT - abdomen
    • History and indication: pain over Rt inguinal region with tenderness for 2 days.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Enlarged LNs (up to 3.1cm) at bil. inguinal regions, RLQ, mesentery and paraaortic region.
      • Left renal cyst (2.4cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Enlarged LNs (up to 3.1cm) at bil. inguinal regions, RLQ, mesentery and paraaortic region (stable condition).
  • 2022-10-18 Patho - lymphnode biopsy
    • Soft tissue, lymph node? inguinal region, right, excision — Granulation tissue
  • 2022-10-15 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Infiltrative soft tissue in the retroperitoneum around the aortocaval region and encasement of SMA/SMV and celiac trunk. Stationary as compare with CT study on 2022-08-19.
      • Left renal cysts, up to 2.8cm.
      • Focal atelectasis in right lung and pleural thickening, stationary.
      • There are lymph nodes in the mediastinum and right hilar region.
      • Coronary artery calcifications.
      • Enlarged right inguinal lymph nodes. Cystic lesion(3.1cm) in right inguinal region with subcutaneous infiltrates and skin thickening. R/O abscess and cellulitis. DDx: lymph node necrosis.
    • Impression:
      • Clinical lymphoma s/p treatment.
      • Enlarged right inguinal lymph nodes. Cystic lesion in right inguinal region with focal fatty infiltrates and skin thickening, r/o absces and cellulitis. DDx: lymph node necrosis.
      • Focal atelectasis in ight lung and pleural thickening, stationary.
      • Coronary artery calcifications.
  • 2022-10-11 CXR
    • Blunted right costophrenic angle.
    • Ground glass opacity in RLL.
  • 2022-08-19 CT - abdomen
    • History: 65 y/o male with Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, MIPI: 6.4 points.
    • Indication: FU mantle cell lymphom over both side of diaphragm
    • Findings
      • Prior CT identified infiltrative soft tissue lesions (confluent enlarged nodes) in the retroperitoneum around the aortocaval region, encasement of SMA/SMV and celiac trunk are noted again, decreasing in size that is c/w Mantle cell lymphoma S/P C/T with partial response.
      • Prior CT identified enlarged lymph nodes in the paratracheal space are noted againm, mild decreasing in size that is c/w mantle cell lymphoma with mediastinum LNs involvement S/P C/T with partial response.
      • There is minimal pleura effusion or reaction in Rt CP angle.
      • There are several renal cysts on left kidney and the largest one measuring 2.3 cm in size at left upper pole.
    • Impression:
      • Mantle cell lymphoma over both side diaphragm S/P C/T show partial response.
    • 2022-05-17 CT - abdomen
      • Clinical history: 65 y/o male patient with Mantle cell lymphoma with bone marrow involvement, Lugano stage IV, MIPI: 6.4 points.
      • Findings
        • Infiltrative soft tissue in the retroperitoneum around the aortocaval region and encasement of SMA/SMV and celiac trunk. Relative regression as compare with CT study on 2022-03-08.
        • Mild right pleural effusion. Focal atelectasis in right lung.
        • There are lymph nodes in the mediastinum and right hilar region.
        • Coronary artery calcifications.
      • Impression:
        • Clinical lymphoma, with mild regression, suggest follow up.
        • Mild right pleural effusion. Focal atelectasis in right lung.
        • Coronary artery calcifications.
    • 2022-04-26 CXR
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
      • Enlargement of cardiac silhouette.
      • Linear opacity projecting at right lower lung show stationary.
    • 2022-04-08 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Mantle cell lymphoma
      • Sections show 20-30 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 0-2/HPF. No increase of blasts is noted. Several foci of aggregation of lympohid cells are seen.
      • The immunohistochemical stains reveal CD20(+), CD3(-), Cyclin D1(+). The results are consistent with Mantle cell lymphoma.
    • 2022-03-08 CT - chest
      • Findings
        • Lungs: subsegmental opacities with extensive septal thickening and peribronchovascular bundle thickening in Rt lung, RML and RLL predominance, in regression as compared with previous CT study on 1/3. a centrilobular nodule at lingula.
        • Mediastinum: extensive lymphadenopathy in visceral and Rt anterior prevascular spaces, in regression.
          • Rt pericardial thickening.
        • Hila: enlarged LN, Rt, in regression.
        • Vessels: extensive coronary arterial calcification
          • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
          • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: small Rt pleural effusion with extensive thick parietal thickening.
        • Chest wall and visible lower neck: residual small and slightly enlarged LNs at Rt axilla and supraclavicular fossae, stationary.
        • Visible abdominal-pelvic contents: moderate splenomegaly.
          • regression of extensive confluent lympapathy in the para-aortic region and msentery root, involving the pancreas, and discrete lymphadopathies in both inguinal regions compared with CT on 20220103
          • a well-defined cystic lesion of water in density (27x34 mm) at Rt inguinal region.
          • a small left renal cyst and wall thickening of.
          • the gallbladder. no focal lesion in the liver and adrenal glands
          • Visualized bones: marginal spurs of vertebrae.
      • Impression:
        • Mantle cell lymphoma in both sides of diaphgram, with regression of lung involvement and slightly regression of extensive lymphadenopathy as compared with CT on 20220103
    • 2022-03-07 Patho - bone marrow biopsy
      • Bone marrow, iliac bone, biopsy — B-cell lymphoma involvement
      • Microscopically, the sections show pictures of extensively crush artifact of bone marrow tissue. The cellularity maybe increased.
      • Immunohistochemistry shows CD3(+, focal), CD20(+), CD5(+), CD34(-) and cyclin-D1(-), compatible with B-cell lymphoma involvement, and mantle cell lymphoma maybe first considered according to past history. Clinical correlation is advised.
    • 2022-01-03 CT - chest
      • Mantle cell lymphoma in both sides of diaphgram, with progression of lung involvement and slightly regression of extensive lymphadenopathy as compared with CT on 20211002
    • 2021-11-03 SONO - chest
      • Pleural effusion, minimal, bilateral, organizing
      • Pleural thickening, bilateral
    • 2021-10-18 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 39) / 131 = 70.23%
        • M-mode (Teichholz) = 70
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction.
      • Mildly dilated LV with normal LV and RV systolic function.
      • Aortic valve sclerosis with mild AR.
      • Mild aoratic root calcification; dilated proximal ascending aorta (38mm).
    • 2021-10-13 Patho - bone marrow biopsy
      • Bone marrow, iliac, clinically: mantle cell lymphoma, biopsy — Lymphoma involvement.
      • IHC stains: Cyclin-D1 (weak +).
      • Section shows piece(s) of bone marrow with 70% cellularity and with a predominant small to intermediate size atypical lymphoid cells.
    • 2021-10-12 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm as mentioned above (at least stage III).
      • Mildly and diffusely increased FDG uptake in the bone marow of the skeleton. The nature is to be determined (lymphoma involving the bone marrow? bone marrow hyperplasia?). Please correlate with other clinical findings for further evaluation.
      • Mildly increased FDG uptake in the right lower lung field and pleura of right lower lung. Inflammation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 2021-10-05 Patho - lymph node region resection
      • Lymph node, right inguinal, excision biopsy —- Mantle cell lymphoma
      • Soft tissue, neck, excision — Consistent with mantle cell lymphoma
      • Histology type: B-cell neoplasms, Mantle cell lymphoma Mantle cell lymphoma — classic,
      • Immunohistochemical stain profiles: CD3(-), CD20(+), CD5(+), CD10(-), BCL2(+), BCL6(-), Cyclin D1(+), Ki-67 is about 10-20%.
    • 2021-10-02 CT - chest
      • Probably lymphoma with mediasitinal, paraaortic, iliac and inguinal lymphadenopathy
      • Pneumonia at right middle lobe and right lower lobe with bilateral pleural effusion.
      • Hepatosplenomegaly.

[chemoimmunotherapy]

  • 2023-05-30 - etoposide 500mg/m2 1000mg NS 50mL 2hr D1-4

    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-4
  • 2022-06-02 - undergoing - Imbruvica (ibrutinib) 140mg/cap 4# QD

  • 2022-04-11 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3

  • 2022-03-11 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP)

  • 2022-02-08 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3

  • 2022-01-04 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5

  • 2021-12-08 - cytarabine 2000mg/m2 3900mg 3hr Q12H D3

  • 2021-12-07 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3

  • 2021-11-16 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5

  • 2021-10-19 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 30mg BID PO D1-5

==========

2022-10-12

  • This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT). As part of this hospitalization, images will be updated.

  • The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.

    • ref:
      • Combining BTK inhibitors with BCL2 inhibitors for treating chronic lymphocytic leukemia and mantle cell lymphoma. Biomark Res. 2022;10(1):17. Published 2022 Apr 4. doi:10.1186/s40364-022-00357-5
      • Dose-finding study of ibrutinib and venetoclax in relapsed or refractory mantle cell lymphoma. Blood Adv. 2022;6(5):1490-1498. doi:10.1182/bloodadvances.2021005357
      • Concurrent ibrutinib plus venetoclax in relapsed/refractory mantle cell lymphoma: the safety run-in of the phase 3 SYMPATICO study. J Hematol Oncol. 2021;14(1):179. Published 2021 Oct 30. doi:10.1186/s13045-021-01188-x

701306067

221011

  • lab data
    • 2022-09-12 Anti-HBs >1000.00 mIU/mL
    • 2021-10-04 ROS1 IHC specimen number S2021-11626
    • 2021-10-04 ROS1 IHC 1+
    • 2021-09-23 EGFR specimen number S2021-11626
    • 2021-09-23 EGFR G719X not detected
    • 2021-09-23 EGFR Exon19 del detected
    • 2021-09-23 EGFR S768I not detected
    • 2021-09-23 EGFR T790M not detected
    • 2021-09-23 EGFR Exon20 ins not detected
    • 2021-09-23 EGFR L858R not detected
    • 2021-09-23 EGFR L861Q not detected
    • 2021-09-23 PD-L1(22C3) specimen number S2021-11626
    • 2021-09-23 PD-L1(22C3) TPS >= 50%
    • 2021-09-23 ALK IHC specimen number S2021-11626
    • 2021-09-23 ALK IHC Negative
  • exam finding
    • 2022-09-14 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2021/09/14, the old lesions at the T10 and L1 spines are more evident; the right rib cage and left S-I joint show stationary, and a new lesion at the sacrum is noted, indicating metastatic bone disease in progression.
      • Suspected benign lesions at bilateral shoulders and hips.
    • 2022-09-12 CXR
      • A poorly defined nodule over Rt lower lobe due to tumor
      • Nodular opacitiy projecting over Lt lower lung zone due to nipple shadow
      • pathological compression fracture of T9 vertebral body
    • 2022-09-01 MRI - brain
      • Findings: Multiple intra-axial enhancing lesions (all smaller than 10 mm) along cortical gyrus or corticomedullary junction of bilateral frontal and temporal lobes, indicating metastases. Increased in number as compared with MRI on 20220502.
      • IMP: Multiple brain metastases. Progressive change as compared with MRI on 20200502.
    • 2022-08-02 CT - lung/mediastinum/pleura
      • stationary in size of primary RLL cancer with two small nodules in the same lobe stationary as compared with CT on 2022/02/16
      • no locoregional recurrent breast tumor.
    • 2022-07-21 CXR
      • Patch density at bil. lungs.
    • 2022-07-21 SONO - abdomen
      • Findings: A hyperechoic nodule (1.40x2.08cm) at S7 of liver. Bil. liver cysts (up to 2.0cm).
      • IMP: A hemangioma (1.40x2.08cm) at S7 of liver. Bil. liver cysts (up to 2.0cm).
    • 2022-05-02 MRI - brain
      • Bifrontal and left temporal metastases.
      • Newly developing right frontal nodules. One lesion of left frontal lobe, seems enlarged.
    • 2022-03-31 SONO - abdomen
      • Left liver cyst (2.48x2.70cm).
      • A hyperechoic nodule (1.53x1.57cm) in S6 of liver suspected hemangioma.
    • 2022-02-16 CT - chest
      • decreased size of primary RLL cancer with two small nodules in the same lobe and mediastinal LAP resolved compared with CT on 2021/9/18.
      • questionable left frontal brain nodule based on noncontrast CT images.
    • 2021-12-15 SONO - abdomen
      • Liver cyst, S4 and S6
      • Liver tumor, suspicious hemangioma, S6
      • Accessory spleen
      • pancreatic tail masked by gas.
    • 2021-11-17 T-, L-spine AP + Lat
      • mild scoliosis of the L-spine.
      • Unremarkable change in the width of the bony spinal canal
      • mild anterior spur formation at the L-spine.
      • decreased disc spaces in the T-spine discs and the middle L-spine discs..
    • 2021-09-18 MRI - brain
      • Left fronto-temporal metastases
      • Suspected Bil. cerebellar metastases.
    • 2021-09-14 Tc-99m MDP whole body bone scan with SPECT
      • In comparison with the previous study on 2021/07/26, the lesions in the T10 spine, L1 spine and left S-I joint are more evident. Bone metastases should be watched out.
      • Some new faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? bone metastases?). Please follow up bone scan for further evaluation.
    • 2021-09-10 CT - chest
      • Indication
        • Right breast cancer proved by CNB on 20210707
        • 20210628
          • Breast lump, right
          • self examination
          • palpable at right/ left breast: yes
      • Findings
        • Chest:
          • Spiculated mass at right lower lobe up to 3.5cm in largest dimension is found. Lung cancer is suspected.
          • Some lymph nodes are found at paratracheal region.
          • No evidence of bilateral pleural effusion.
          • S/P mastectomy at right side.
        • Visible abdomen:
          • Hepatic simple cysts at both lobes of liver up to 2.3cm at S1 and 1.5cm at S7/8.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • Imp: left lower lobe lung cancer with medistinal lymph nodes, T2aN2M0
      • Imaging Report Form for Lung Carcinoma
        • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2021-09-01 Patho - lung wedge biopsy
      • Lung, right, CT-guide biopsy — adenocarcinoma, moderately to poorly differentiated, in favor of lung primary tumor
      • Sections show solid nests and neoplastic glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(focal +), Napsin A(focal +), GATA3(focal weak +), Mammaglobin (-), ER(-), PR(-), and HER2(2+, equivocal). The Ki-67 is about 50%. The results are in favor of primary lung adenocarcinoma.
    • 2021-08-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (80.42 - 13.74) / 80.42 = 82.91%
      • LVEF = 65 (%)
        • M-mode (Teichholz) = 70.97
      • Normal AV/MV with no AR/MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, mild TR, normal IVC size
    • 2021-08-23 Peripheral Vascular Test - vein, lower limbs
      • Clinical diagnosis: edema
      • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
        • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
        • Spontaneous signal A N N N N N N A N N
        • Respiratory changes A N N N N N N A N N
        • Cough response A N N N N N N A N N
        • Compression study A N N N N N N A N N
      • Report:
        • Right side:
          • SVC: 16.3 mmHg ; 17.6 mmHg ;
          • MVO/SVC: 99 % ; 97 % ;
          • Average MVO/SVC: 98.00 %
        • Left side:
          • SVC: 17.0 mmHg ; 17.0 mmHg ;
          • MVO/SVC: 100 % ; 100 % ;
          • Average MVO/SVC: 100.00 %
        • Thrombus : None
        • Varicose vein : None
      • Conclusion:
        • A perforator vein connecting the right PTV and LSV at middle lower leg level, but no engorgement of LSV was noted. Increased venous return flow velocity at right CFV. Tissue edema at right lower leg.
        • Mild venous reflux at left popliteal vein; mild veonus reflux at left popliteal vein; a perforator vein connecting the left PTV and LSV at middle lower leg level, but no engorgement of LSV was noted. Tissue edema at left lower leg.
        • No evidence of venous thrombosis at bilateral lower limbs venous systems.
        • The ratios of MVO and SVC of bilateral legs were within normal limits.
    • 2021-07-28 Whole body PET scan
      • Glucose hypermetabolism in the right lower lung, probably another primary (priority) or secondary lung malignancy, suggesting biopsy for further investigation.
      • Glucose hypermetabolism in the right SCF lymph nodes, bilateral mediastinal lymph nodes, and right pulmonary hilar lymph nodes, probably lung cancer with regional lymph nodes metastases, suggesting biopsy for further investigation also.
      • Glucose hypermetabolism in the right rib cage, T10 and L1 spines, and left iliac bone, probably lung cancer with multiple bone metastases.
      • Increased FDG uptake at the initial end of A-colon, the nature is to be determined (physiological uptake of FDG, polyp, or other nature ?), suggesting colon fibroscopy for investigation.
      • Increased FDG uptake at the left shoulder, probably post-traumatic change.
      • Right breast cancer s/p treatment, no evidence of residual tumor; right lower lung cancer (if proved), cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2021-07-27 Patho - breast simple/partial mastectomy
      • pathologic diagnosis
        • Breast, right, simple mastectomy — Invasive carcinoma of no special type
        • Resection margin, breast, right, simple mastectomy — Free
        • Lymph node, sentinel, right axilla, SNLB — Negative for malignancy (0/1)
        • AJCC 8 th edition, Pathology stage: pT2N0; Anatomic stage IIA; Prognostic stage IIA if cM0
      • microscopic examination
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 3.5 x 3.0 x 3.0 cm
        • Histologic grade (Nottingham histologic score): Grade 3 (score = 8)
        • Skin involvement: Absent
        • Ductal carcinoma in situ (DCIS): Present; Extensive DCIS: Negative
        • Margins: Negative, Closest margin ( 2 mm from base margin)
        • Nodal status: Negative (sentinel 0/1)
          • number of lymph node examined: 1 (sentinel)
          • number with macrometastases (>2mm): 0 (sentinel)
          • number with micrometastases (>0.2~2mm and/or >200 cells): 0
          • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
        • Treatment Effect: No presurgical neoadjuvant therapy received
        • Lymphovascular invasion: Presnt
        • Perineural invasion: Absent
        • Representative parts are taken for section and labeled: A1 = nipple, A2-A4 = tumor + base margin, A5-A7 = tumor + skin, A8 = non-tumor. F2021-000286 FSA= sentinel lymph node, FSB= skin.
      • IMMUNOHISTOCHEMICAL STUDY (S2021-08728)
        • ER (Ab): Positive (strong, >90%)
        • PR (Ab): Negative
        • HER-2/Neu (Ab): Equivocal (score= 2+)
        • Ki-67: 10%
        • p53: Positive
      • IN-SITU HYBRIDIZATION (S2021-08728)
        • HER2/NEU In-Situ Hybridization: Neagtive.
        • There is NO amplification of HER2 detected
    • 2021-07-27 Lymphoscintigraphy
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
      • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
    • 2021-07-26 CT - abdomen
      • A tumor (2.5cm) at RLL.
      • Retroversion of uterus.
      • Liver cysts (up to 2.3cm).
    • 2021-07-26 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the maxilla, a middle C- spine,T10 and L3-4 spines, sacrum, bilateral shoulders, S-I joints, and hips.
    • 2021-07-26 SONO - abdomen
      • Hepatic tumor, S7
      • Hepatic cysts
      • Parenchymal liver disease
      • Parenchymal renal disease
    • 2021-07-23 Mammography
      • S/P right mastectomy.
      • No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative.
    • 2021-07-02 Patho - breast biopsy (no margin)
      • Breast, right, sono guide biopsy— invasive carcinoma of no special type
      • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis. The tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.
      • IHC stain— ER:positive (strong, > 90%), PR: negative, Her2/neu: equivocal (2+), Ki-67 index: 10%, P53: positive
      • HER2/NEU In-Situ Hybridization — Neagtive: There is NO amplification of HER2 detected.
    • 2021-07-02 SONO - breast
      • Right breast tumor, suspected malignancy.
      • Complex cystic tumor in right breast, 10’region.
      • Right axillary lymph node, suspected metastasis.
  • consultation
    • 2022-09-30 Dermatology
      • Q
        • Consult for pressure sore with necrosis and of buttock
        • This 70-year-old woman had history of
          • Right breast cancer s/p simple mastectomy and SLNB on 20210727, T2N3M1, Stage IV
          • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 20210915.
        • Falling accidence for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea for more weeks, suspect Iressa side effect.
        • Brain MRI on 2022-09-01 showed multiple brain metastases. Progressive change as compared with MRI on 20200502.
        • Thus she was admitted to our chest ward for further exam with treatment.
        • After admission, pressure sore with necrosis and of buttock was noted, aerobic culture of pus grown Staphylococcus.
        • Wet dressing with diluted betaiodine (1:1) gauze BID not improve due to nearly bed riddeen and poor nutrition.
      • A
        • This patient suffered from one ulceration on L’t buttock for days.
        • Imp: Bedsore
        • Suggestion:
          • Doxyclin 1 /Bid
          • Fuciden * 2 tube/bid
          • ZnO * 1 tube/bid
    • 2022-09-15 Infectious Disease
      • Q
        • Consultation for Zyvox
      • A
        • Patient’s sacral pressure sore wound culture showed MSSA infection.
          • There is penicillin anaphylactic shock history that use of penicillin should be avoided.
          • From the MSSA antibiogram, Baktar, Avelox, and Cipro all susceptible.
          • Use of Zyvox should be not necessary.
        • Suggestion:
          • DC Zyvox.
          • Add oral Avelox or Cipro for coverage of bedsore MSSA infection.
    • 2022-09-12 Plastic and Reconstructive Surgery
      • Q
        • Consult for open wound of buttock
        • This 70-year-old woman had history of
          • Right breast cancer s/p simple mastectomy and SLNB on 2021-07-27, T2N3M1, Stage IV
          • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021-09-15.
        • Falling accidence for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea for more weeks, suspect Iressa side effect.
        • Brain MRI on 2022-09-01 showed multiple brain metastases. Progressive change as compared with MRI on 20200502. Thus she was admitted to our chest ward for further exam with treatment.  
        • After admission, pressure sore with pus of buttock was noted, aerobic and anarobic culture of pus was collect.
        • We need your professional expertise for help, thank you very much.
      • A
        • This is a case of pressure sore with necrosis and cellulitis of the sacrum.
        • Suggestion
          • The conservative treatment
            • antibiotic use;
            • wet dressing with diluted betaiodine (1:1) gauze bid;
            • avoiding the supine position;
            • nutrition supportion
          • and observation are suggested.
    • 2022-09-12 Radiation Oncology
      • Q
        • Consult for brain radiotherapy
        • This 70-year-woman had history of
          • Right breast cancer s/p simple mastectomy and SLNB on 2021-07-27, T2N3M1, Stage IV
          • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021-09-15.
        • Falling accidence for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea for more weeks, suspect Iressa side effect. Brain MRI on 2022-09-01 showed multiple brain metastases. Progressive change as compared with MRI on 20200502.
        • Thus she was admitted to our chest ward for further exam with treatment.  
        • Due to multiple brain metastasis, we need your professional expertise for radiotherapy, thank you very much.
      • A
        • Subjective:
          • History: This 70-year-woman had history of
            • Right breast cancer s/p simple mastectomy and SLNB on 2021/07/27, cT2N3M1, Stage IV;
            • Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021/09/15.
          • Falling accidence was noted for 2 times in 2022/07 (also Zoledronic acid). Nausea with diarrhea was noted for more weeks, suspect Iressa side effect. Brain MRI on 2022-09-01 showed multiple brain metastases, with progressive change as compared with MRI on 20200502. Poor intake and dehydration due to nausea has been noted for weeks.
          • Previous RT: denied.
          • Other disease: as above.
          • Family history: denied.
            • Habit: Alcohol, denied; smoking: denied; betel nuts: denied.
            • Single. Caregiver: her friend. Job: nil. Mild economic stress.
            • Language: Taiwanese. Mandarin.
            • Religion: Buddism.
        • Objective:
          • General Condition-ECOG: 1.
          • PE, 2022/09/12: No palpable neck LNs.
          • Pathology, 2021/09/01: Lung, right, CT-guide biopsy — adenocarcinoma, MD to PD, in favor of lung primary tumor. TTF-1(focal +), Napsin A(focal +), GATA3(focal weak +), Mammaglobin (-), ER(-), PR(-), and HER2(2+, equivocal). The Ki-67 is about 50%.
          • Images:
            • Brain MRI, 2022/05/02: Bifrontal and left temporal metastases. Newly developing right frontal nodules. One lesion of left frontal lobe, seems enlarged.
            • Brain MRI, 2022/09/01: Multiple intra-axial enhancing lesions (all smaller than 10 mm) along cortical gyrus or corticomedullary junction of bilateral frontal and temporal lobes, indicating metastases. Increased in number as compared with MRI on 20220502. IMP: Multiple brain metastases. Progressive change as compared with MRI on 20200502.
            • Chest CT, 2022/08/02: stationary in size of primary RLL cancer with two small nodules in the same lobe stationary as compared with CT on 2022/02/16; no locoregional recurrent breast tumor.
        • Diagnosis: Lung cancer, adenocarcinoma, cT2aN2M1c, stage IVB, with bone, brain metastasis, ECOG 1, under Iressa since 2021/9/15 with progressive brain metastasis; ECOG 2; poor intake & dehydration.
        • Goal of radiotherapy: Palliative.
        • RT Plan:
          • Target & Volume: Brain metastasis (n=15) with sparring of hippocampus.
          • Technique: VMAT.
          • Dose & Fractionation: 3960cGy/12 fractions.
          • Plan: Brain RT for 3960cGy/12 fractions is suggested for symptom control. First fraction was prescribed smoothly on Sep 12, 15:00. Possible radiation side effects are told to the patient and her friend. Please prescribe adequate dose of dexamethasone and Famotidine to prevent IICP during brain RT. IV fluids may be prescribed due to poor intake & dehydration.
  • surgical operation
    • 2021-07-27 Simple mastectomy + SLNB    
      • right breast tumor 3cm, 1-2 oclock/1cm from nipple
      • axillary sentinel lymph node: 0/1
  • chemoimmunotherapy
    • 2022-01-12, 2022-02-09 - zoltedronic acid 4mg IVD (for bone mets)
    • 2021-09-23 ~ undergoing - Iressa (gefitinib 250mg/tab) 1# QD
    • 2021-09-22 ~ 2022-05-25 - Kisqali (ribociclib 200mg/tab) 2# QD
    • 2021-08-11 ~ undergoing - Femara (letrozole 2.5mg/tab) 1# QD

[assessment]

  • The patient has been diagnosed with ER(+) PR(+) HER2(-) breast cancer and has been treated with letrozole, an aromatase inhibitor, in combination with the CKD4/6 inhibitor, ribociclib (2021-09-22 ~ 2022-05-25).

  • She was also diagnosed with EGFR Exon19 deletion, PD-L1 TPS >= 50% lung adenocarcinoma, and is currently undergoing the TKI gefitinib (2021-09-23 ~ undergoing).

  • The use of atezolizumab might be an option for her subsequent treatment, as her lung cancer is also characterized by PD-L1 TPS >= 50%. (2021-09-23 S2021-11626)

  • Her bone mets were treated with zoltedronic acid (2022-01-12, 2022-02-09) and two falling accidents were noted in July 2022. In the event that zoltedronic acid is not well tolerated by the patient, Xgeva (denosumab 120mg SC) or romosozumab (currently not available at this hospital) might be an alternative.

700199371

221007

  • exam finding
    • 2022-08-13 Gynecologic ultrasonography
      • ATH + BSO
      • Suspected Lt adnexal cyst (26mmx22mm)
      • Suspected Rt mass? (39mmx30mm), RI:0.65
    • 2022-07-22 CT - abdomen
      • Local recurrent tumor 3.7 cm in left pelvis is suspected. please correlate with clinical condition.
      • Metastatic node 3.1 cm in pre-cava space.
        • In addition, several metastatic nodes in para-aortic space and para-cava space, bilateral common iliac chain, and bilateral inguinal area are highly suspected.
    • 2022-05-07 Gynecologic ultrasonography
      • ATH + BSO
      • Suspected Lt adnexal cyst (29mmx28mm)
      • Suspected Rt mass? (37mmx30mm)
    • 2022-04-27 CT - abdomen
      • Prior CT identified a soft tissue mass measuring 2.7 cm in left pelvis is noted again, mild increasing in size to 2.9 cm. Follow up is indicated.
    • 2022-01-27 CT - abdomen
      • S/P hysterectomy. A soft tissue tumor (2.7cm) at left pelvic cavity. A cystic lesion (2.2x6.3cm) at left pelvic cavity.
      • Grade 4 fatty liver.
    • 2021-11-08 SONO - abdomen
      • Fatty liver.
      • Hypoechoic lesion, 1.72x0.93cm in pericholecystic region, suspected focal fatty sparying. Suggest follow up.
      • Left renal cyst.
    • 2021-08-25 Tc-99m MDP whole body bone scan with SPECT
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the skull, maxilla, upper L-spine, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet.
    • 2021-08-18 MRI - pelvis
      • S/P hysterectomy.
      • Suspected hematoma (1.5cm) around left aspect of vaginal stump, suggest follow up.
      • Left pelvic cavity cystic lesion, suspected lymphocele, suggest follow up.
      • Bone lesion in right sacrum, 1cm, bone metastasis? suggest bone scan study.
    • 2021-05-17 MRI - pelvis
      • S/P hysterectomy.
      • Small peritoneal nodule (0.48cm) in lower pelvic cavity, carcinomatosis? Suggest follow up.
      • Suspected hematoma (1.3cm) around left aspect of vaginal stump, suggest follow up.
      • Suspected lymphocele in left pelvic cavity, suggest follow up.
    • 2020-10-31 Gynecologic ultrasonography
      • ATH + BSO
      • Suspected Lt adnexal cyst (58mmx42mm), no blood flow
    • 2020-09-17 Patho - uterus (with or without SO) neoplastic
      • PATHOLOGIC DIAGNOSIS
        • Endometrium, uterus, staging surgery — Endometrioid carcinoma, grade 2
        • Myometrium, uterus, ditto — Tumor invasion, more than half thickness, leiomyomas
        • Cervix, uterus, ditto — Free of tumor invasion, Nabothian cyst
        • Ovary, left, ditto — Free of tumor invasion, hemorrhagic corpus luteum
        • Fallopian tube, left, ditto — Free of tumor invasion
        • Ovary, right, ditto — Free of tumor invasion, hemorrhagic corpus luteum
        • Fallopian tube, right, ditto — Free of tumor invasion
        • Lymph node, left external iliac, dissection — Tumor metastasis (3/10) with extracapsular extension (3/3)
        • Lymph node, left oburator, ditto — Tumor metastasis (5/9) without extracapsular extension (0/5)
        • Lymph node, right external iliac, ditto — Tumor metastasis (1/5) without extracapsular extension (0/1)
        • Lymph node, right oburator, ditto — Tumor metastasis (2/12) without extracapsular extension (0/2)
        • Lymph node, left para-aortic, ditto — Free of tumor metastasis (0/7)
        • Parametrium, bilateral — Free of tumor
        • Cul-de sac tumor, excision — Endometrioid carcinoma
        • Serosal nodule, uterus — Endometrioid carcinoma
        • Vaginal stump — Free of tumor
        • AJCC Pathologic stage — pT3aN1a (if cM0), stage IIIC1 (FIGO stage IIIC1)
      • MACROSCOPIC EXAMINATION
        • Operation Procedure: staging surgery (TAH, BSO and BPLND)
        • Specimens include: Uterus, bilateral ovaries and fallopian tubes, pelvic LNs and cul-de sac tumor
        • Specimen size:
          • uterus: 15.2 x 12.3 x 7.5 cm in size, and 552 gm in weight contains myomas and one serosal nodule
          • right ovary: 3.6 x 1.8 x 1.4 cm
          • left ovary: 3.4 x 2.2 x 1.2 cm
          • right tube: 6.5 cm in length; 0.6 cm in diameter
          • left tube: 6.9 cm in length; 0.7 cm in diameter
        • Tumor site: endometrium, from fundus to endocervix
        • Tumor size: 11.6 x 8.3 x 4.2 cm
        • The myometrium: up to 3.2 cm in thickness
        • The cervix : mucoid cysts
        • Adnexa (bilateral): not invaded by tumor
        • Lymph nodes: left external iliac LNs; left obturator LNs; right external iliac LNs, right obturator LNs and left para-aortic LNs
        • cul-de sac tumor: one small piece, 2.4 x 1.8 cm
        • Serosal nodule of uterus: 1.2 x 0.8 x 0.7 cm
      • MICROSCOPIC EXAMINATION
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 2
      • Depth of invasion: More than half thickness of myometrium
      • Lymphovascular invasion: Present
      • The cervical stroma involvement:: absent
      • Resection margins of the cervix: Free, 3.2 cm away from tumor cells
      • Additional pathologic findings: N/A
      • Lymph nodes: tumor metastasis (11/43) with extracapsular extension (3/11) in total number
      • Vaginal stump: 0.8 cm, free
      • Immunohistochemistry: WT-1(-), ER(+), PR(+), PAX-8(+) and vimentin(+, scatter) for tumor cells
      • Cul-de sac tumor: endometrioid carcinoma
      • Serosal nodule of uterus: Endometrioid carcinoma
    • 2020-08-28 MRI - pelvis
      • Findings
        • Diffuse soft tissue tumor, up to 8.8cm in the uterine cavity (fundus, body to the eneocervical region), suspected endometiral malignancy.
        • Soft tissue tumors in the cul-de-sac with ascites, suspected tubal or ovarian involvement.
        • There are T2 hypointensity tumors, up to 1.8cm in the uterine myometrium, suspected uterine myomas.
        • There are diffuse enlarged lymph nodes in bilateral obturator, intenal, external and common iliac regions, could be due to metastatic lymph nodes.
        • Non-enhancing nodules in bilateral kidneys, suspected renal cysts.
      • Imaging Report Form for Endometrial Carcinoma
        • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE: III (Stage_value)
        • Diffuse soft tissue tumors in the uterine cavity with diffuse enlarged lymph nodes in the pelvic cavity, suspected endometrial malignancy with lymph nodes metastasis.
        • Soft tissue tumors in the cul-de-sac with ascites, suspected tubal or ovarian involvement. cstage T3N1M0.
    • 2020-08-21 Patho - endometrium curretage/biopsy
      • Endometrium, uterus, D&C — Adenocarcinoma
    • 2020-08-15 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • Suspected endometrial hyperplasia
      • Uterine myoma
    • 2020-06-27 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • EM: 22.6m
      • Uterine myoma
  • chemoimmunotherapy
    • 2022-10-06 - docetaxel 75mg/m2 135mg 1hr + carboplatin AUC 5 550mg 2hr
    • 2022-09-15 - bevacizumab 7.5mg/kg 570mg 1.5hr + docetaxel 75mg/m2 135mg 1hr + carboplatin AUC 5 550mg 2hr
    • 2022-08-25 - bevacizumab 7.5mg/kg 570mg 1.5hr + docetaxel 75mg/m2 135mg 1hr + carboplatin AUC 5 550mg 2hr
    • 2022-08-04 - bevacizumab 7.5mg/kg 590mg 1.5hr + docetaxel 60mg/m2 100mg 1hr + carboplatin AUC 5 560mg 2hr
    • 2021-02-02 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2021-01-12 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2020-12-22 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2020-12-01 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2020-11-10 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
    • 2020-10-20 - paclitaxel 160mg/m2 270mg 3hr + carboplatin AUC 5 450mg 2hr

[assessment]

Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;73(11):1336-1349. doi:10.1016/j.jacc.2019.01.017

Johnstone C, Rich SE. Bleeding in cancer patients and its treatment: a review. Ann Palliat Med. 2018;7(2):265-273. doi:10.21037/apm.2017.11.01

  • There has been an observation of vaginal bleeding possibly caused by bevacizumab. A transfusion might be necessary if there is a significant loss of blood (which is not the case for this patient HGB 11.0 g/dL 2022-10-06).

  • Tranexamic acid has not been studied in advanced cancer, but it reduces mortality due to bleeding by approximately one-third. A reduction of approximately one-third in blood loss and transfusion requirements has been seen in meta analyses of its use in elective surgery as well.

    • ref: Ker K, Edwards P, Perel P, et al. Effect of tranexamic acid on surgical bleeding: Systematic review and cumulative meta-analysis. BMJ 2012;344:e3054.
    • ref: Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss. Br J Surg 2013;100:1271-9.
  • No dose-response has been seen for tranexamic acid’s therapeutic effect, and the recommended dose is 10 mg/kg per dose given intravenously every 6-8 hours, with no benefit to doses above 1 gram.

    • ref: Hunt BJ. The current place of tranexamic acid in the management of bleeding. Anaesthesia 2015;70 Suppl 1:50-3, e18.

701453252

221007

Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets with Paclitaxel and Gemcitabine Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa Malignant neoplasm of unspecified site of left female breast

  • past history
    • Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver metastasis s/p pancreaticoduodenectomy, Level 3 mesopancreas dissection, cholecystectomy and wedge biopsy of liver, laparotomy on 2021/01/19 & s/p palliative chemotherapy with Paclitaxel and Gemcitabine
    • Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa s/p totally laparoscopic distal gastrectomy (TLDG) with D2 lymphadenectomy (LND) on 2018/07/16 & s/p adjuvant chemotherapy + radiotherapy
    • Left breast cancer, intraductal papilloma with ductal carcinoma in-situ, pTis, stage 0 s/p excision on 2018/11/30 & s/p hormone therapy with Femara since 2019/02/15 + radiotherapy till 2019/04/10
    • Peptic ulcer more than 10 years ago
    • Hypertension for years without medical control
    • Severe narrowing of left C5/6 and C6/7 neural foramina, caused by protusion disc plus compressin of left C6 and C7 nerve roots, then left upper and lower limbs muscle weakness
  • op history
    • Left femur intertrochanteric displaced fracture, with posteromedial involvement to lesser trochanter status post open reduction and internal fixation with Gamma nail on 2022/09/23
    • s/p lumbar spine (L4/5) surgery in 2011 and s/p cervical spine (C3) surgery in 2014
    • C/S in 1986.
  • exam findings
    • 2022-10-06 CT - abdomen
      • Findings
        • S/P gastric and pancreas operation.
        • Heterogeneous density of liver with some poor enhancing nodules.
        • Multiple nodules at bil. lungs. Left pleural effusion with adjacent lung collapse.
        • Soft tissues in peritoneal cavity.
        • Mild dilatation of IHDs.
        • Massive ascites.
        • General subcutaneous edema.
        • Enlarged LNs at mediastinum, mesentery and retroperitoneum.
      • Impression
        • S/P gastric and pancreas operation. In favor of peritoneal seeding, LNs, lung and liver metastases. Ascites and pleural effusion.
    • 2022-09-26 Patho - bone biopsy/curetting
      • Labeled as “breast cancer, suspected mets; left femur fracture”, ORIF with Gamma nail — fractured bone tissue with no metastatic carcinoma in this specimen.
      • IHC stains: CK (-), GATA-3 (-).
    • 2022-09-23 Pelvis-THR & Lt. Hip Lat
      • Left femoral intertrochanteric fracture, s/p ORIF
      • Acceptable alignment
    • 2022-09-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (117 - 31) / 117 = 73.50%
        • M-mode (Teichholz) = 73.4
      • Dilated LA
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild PR, TR
      • Mild Pulmonary HTN
      • Redundent mitral chordae tendinae
    • 2022-08-03 TS-1 (1-1); 08-24 (1-2)
    • 2022-07-27 Abdominal CT
      • There is a 1.3cm nodule with enhanced wall and low density center in S3 liver.
      • There are tiny nodules in bilateral lung base. Pneumobilia noted.
      • There is a 1.0cm enlarged lymph node in paraaortic region.
      • stable disease.
    • 2022-07-25 Visit Yuli TzuChi hospital due to fall down on 20220721.
      • X-ray showed left medial curneiform, left 2~4th metatarsal base linear fracture.
    • 2022-05-12 Onivyde + 5-Fu/LV (7); 05-25 (8); 06-08 CEA: 28, CA 19-9: 3676, Onivyde + 5-Fu/LV (9); 06-22 (10); 07-06 (11); 07-20 (12)
    • 2022-04-21 CT - abdominal
      • Metastatic tumor in S3 liver is likely.
      • Pneumobilia.
      • Metastatic tumors in bilateral lung base is likely;
      • S/P L4-5 disc spacer implantation.
      • The liver tumor lesion was similar in size (1.2 cm -> 1.5 cm). So called lung lesions were very small (less than 0.5mm, need to follow up).
      • Stable condition.
    • 2022-02-17 Onivyde + 5-Fu/LV (2); 03-03 (3); 03-17 (4); 03-31 (5); 04-14 (6)
    • 2022-02-04 Onivyde + 5-Fu/LV (1), 80% dose, use TS-1 to replace CI 5-Fu (due to port-A on right thigh and relative need help in daily activity due to chronic leg problem).
    • 2022-01-17 Hb 7.8 g/dL -> PRBC 2 u
    • 2021-12-08 Gemzar + Nab Paclitaxel (6/D15); 12-16 (7/D1); 12-29 (7/D8); 111-01-05 (7/D15), CEA 10.5 ng/mL, CA 19-9: 414 U/mL
    • 2021-11-30 CT - chest and abdominal
      • A 1.2 cm rim-enhancing nodular lesion in the S3 of liver, suspicious metastasis. Tiny nodular opacity in lateral segment of RML of the lung.
      • Discuss with patient about her condition and treatment options. Keep current chemotherapy and suggest patient weekly chemotherapy first for better efficacy. If patient can not return to clinics weekly, consider change to 2nd line chemotherapy with Onivyde + 5-Fu/LV. She prefer to keep current treatment because she also had some difficulty in using continuous infusion.
    • 2021-08-18 Gemzar + Nab Paclitaxel (4/D1); 08-30 CEA 3.1 ng/mL, CA 19-9: 185 U/mL; 09-01 Gemzar + Nab Paclitaxel (4/D8); 09-15 (4/D15); 09-29 (5/D1); 10-11 CEA: 3.8 ng/mL, CA 19-9: 219.1 U/mL; 10-13 (5/D8); 10-27 (5D15); 11-10 (6/D1); 11-24 (6/D8); CEA 6.0 ng/mL, CA 19-9 294.7 U/mL
    • 2021-08-04 CT - chest
      • A tiny nodular opacity in lateral segment of RML of the lung, less than 3 mm in size, which was too small to be characterized.
      • A small L.N. in Lt. para-aortic retroperitoneum, showed decreased nodal size compared with prior CT images on 2021/04/28.
      • Pneumobilia in the liver.
    • 2021-07-28 CXR
      • Opacity in right medial mid-lung.
    • 2021-05-12 SONO - breast
      • No evidence of local recurrence.
    • 2021-05-03 Gemzar + Nab Paclitaxel (1/D1); 05-19 (1/D8); 06-02 (1/D15); 06-16 (2/D1); 06-30 (2/D8), CEA 3.9 ng/mL, CA 19-9 307.9 U/mL; 07-14 (3/D15)
    • 2021-04-28 CT - abdomen
      • Metastatic lymphadenopathy in paraaortic region.
    • 2021-02-18 TS-1 (1), 2 weeks on and 1 week off; 03-29 CEA 14.9 ng/mL, CA 19-9 4812 U/mL, 04-01 Gemzar (1/D1); 04-12 (1/D8)
    • 2021-01-19 Open PD and partial hepatectomy
      • Pancreas, head, pancreaticoduodenectomy, ductal adenocarcinoma (pT2N2); Liver, wedge biopsy, ductal adenocarcinoma, metastatic (x2); Gallbladder, cholecystectomy, chronic cholecystitis with cholesterolosis; Lymph node, regional, lymphadenectomy, adenocarcinoma, metastatic (1/2); Lymph node, regional, ALN, lymphadenectomy, adenocarcinoma, metastatic (4/9); CDX-2 (+), CK7 (-) and CK20 (-).
      • Pancreatic cancer with liver mets. Palliative IV chemotherapy with Gemzar + Abraxane was suggested but she took TS-1 due to her preference of oral chemotherapy after detailed discussion.
    • 2021-01-12 PES
      • GERD LA A
    • 2020-12-31 CT - chest
      • No active or space occupying lesion was found in the lung.
      • Increased soft tissue mass in hepatoduodenal ligament and portocaval space of middle abdomen, associated with IHDs dilation, suspect metastatic LAPs.
    • 2020-12-07 MRI - brain
      • old infarction.
      • no definite brain mets.
    • 2020-11-23 Mamography
      • Category 0 (according to ACR BI-RADS categories for mammographic lesions): (a) From chart record: Received left breast intraductal papilloma (IDP) excision on 2018-11-30, pathology revealed: intraductal papilloma with ductal carcinoma in-situ (pTis). (b) Post operative changes ofleft breast. (c) Benign calcification in left breast UOQ (upper outer quadrant). (d) Recommend sonography as complementation.
    • 2020-11-23 CT - abdominal
      • Slight more dilated biliary tree than before. Otherwise, stationary status.
    • 2020-08-27 Chest/Abdomen CT
      • Post distal gastrectomy for gastric cancer as told.
      • No apparent radiological sign of local recurrence or distant metastasis noted from present imaging scope.
      • Known post excision for left breast malignancy. Favor no apparent recurrence.
      • Mild scars in LUL (left upper lung) lingular lobe.
    • 2020-03-10 PES at Yuli hospital
      • BII, GERD.
    • 2018-11-30 Patho
      • Breast, left, ductography and excision, intraductal papilloma with ductal carcinoma in-situ (pTis).
      • ER (+++,98%), PR (+++,90%), Her-2/neu (0, negative), ki67 (+, 3%), p63 (reduced myoepithelial cells) and CK5/6 (loss of expression in DCIS)
    • 2018-11-30? SONO - breast
      • Scar at the LT breast. Several uneven size breast cysts, cystic lesions and fibroadenomas noted in both breasts, favor benign findings. No nipples retraction, bil. No abnormal lymphadenopathy in bilateral axillary regions.
      • Chest X-ray: Mild emphysematous lungs but apparent active lung lesion.
  • consultation
    • 2022-09-24 Orthopedics
      • Q
        • left hip painful disability
        • no HI, no ILOC
        • NKDA
        • PH: gastric (stage III) and pancreatic cancer (stage IV) f/u at HuaLien TzuChi Hospital s/p OP and C/T
        • OP hx: cervical and lumbar spondylosis s/p OP with left side weakness and paresthesia
      • A
        • 68 y/o female
          • past history:
            • gastric (stage III) and pancreatic cancer (stage IV) f/u at HuaLien TzuChi Hospital s/p operation (2018 and 2019) and chemotherapy
            • cervical spondylosis S/P anterior instrumentation of C3
            • Severe spinal stenosis at C5/6 level, caused by posterior central disc protusion. Compression of cervical cord.
            • Severe narrowing of left C5/6 and C6/7 neural foramina, caused by protusion disc. Compressin of left C6 and C7 nerve roots. => Left upper and lower limb muscle weakness
            • Lumbar spondylosis s/p instrumentation of L4/L5
          • Allergy: NKDA
          • No current anti-platelet/anti-coagulation medication usage
          • NPO: since 0900
          • Subjective fall down at home last night, left hip painful swelling and deformity
            • NO ILOC, no head/chest/abdomen trauma
          • PE:
            • Inspection: Left hip flexion deformity
          • Palpation: Left hip tenderness, aggravated when motion
          • Motion: difficult on LEFT hip motion
          • Distal sensation: intact
          • Circulation: Capillary refill time <2sec, dorsalis pedis pulse(+)
          • X-ray:
            • Left femoral intertrochanteric fracture, with posteromedial involvement to lesser trochanter
        • Plan:
          • Arrange 2D cardiac echo for preoperative evaluation
          • Blood transfusion if Hb <10 mg/dL
          • Pain control
          • High mortality risks of hip fracture (50% if non-operation in one year; 20% if operation in one-year) had detail explained to family and patient
          • Arrange ORIF with Gamma nail today
  • SOP
    • 2022-09-28 Hemato-Oncology
      • Impression:
        • Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets
        • Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa
        • Breast cancer, Tis, stage 0
      • Suggestion:
        • Explain to patient about the chemotherapy (Regimen: Abraxane + Gemzar) for her pancreatic caner - benefit / side effects were informed. Questions were all answered. She agreed with the chemotherapy. Breast surgeon suggest hormone therapy (AI) + radiation for her breast cancer in situ. Keep AI.
        • Educate patient about the side effects of chemotherapy, return to clinic or ER if any discomfort.
        • Symptomatic treatment. Add H2 blocker for epigastric pain and educate self care.
      • Keep current chemotherapy and suggest patient keep weekly chemotherapy first for better efficacy. Change to 2nd line chemotherapy with Onivyde + 5-Fu/LV. Might need use TS-1 or UFUR to replace CI 5-Fu (due to port-A on right thigh and relative need help in daily activity due to chronic leg problem).
      • Explain to patient about her CT - stable disease. Keep TS-1 as maintenance and also for her recent leg fracture. Consider change to Cisplatin + 5-Fu if disease progression.
  • chemoimmunotherapy 2022-10-06 ~ undergoing - TS-1

[assessment]

  • Following the administration of 10 units of human insulin, the blood sugar level decreased from 404mg/dL to 155mg/dL.
  • Since the blood sugar level has returned to relative normal, current ‘insulin 10 units QD’ might be switched to PRN in order to prevent hypoglycemia.
  • To determine the pattern of blood sugar levels, please continue to monitor them.

700972259

221006

{HCC with lung & bone metastasis, suspected a large tumor at L5 vertebral body, R paravertebral / R perivertebral spaces}

  • past history
    • Mitral valve prolapse,
    • Hepatitis B carrier,
    • Gastric ulcer,
    • chronic rhinitis s/p radiofrequency turbinoplasty on 20081202,
    • Duodenal ulcer induce peritonitis with pneumoperitonium post Laparoscopic simple closure on 20090830,
    • HBV related liver cirrhosis, child A
    • Hepatocellular carcinomas, bilateral, cT3N0M0 stage IIIa, Barcelona Clinc Liver Cancer stage B diagnosis on 20200107
      • 1st TACE on 20200107 and 2nd TACE 20200206.
  • lab data
    • AFP
      • 2022-03-18 16.9 ng/mL
      • 2022-03-07 12.2 ng/mL
      • 2022-01-05 11.0 ng/mL
      • 2021-11-23 24.6 ng/mL
      • 2021-09-06 32.5 ng/mL
      • 2021-06-22 49.7 ng/mL
      • 2021-02-16 6.3 ng/mL
      • 2020-12-29 3.2 ng/mL
      • 2020-10-27 3.6 ng/mL
      • 2020-10-27 3.9 ng/mL
      • 2020-08-18 7.1 ng/mL
      • 2020-04-20 3.2 ng/mL
      • 2020-03-05 3.6 ng/mL
      • 2020-02-05 2.7 ng/mL
      • 2019-12-09 2.8 ng/mL
      • 2019-09-16 3.0 ng/mL
      • 2019-01-09 3.0 ng/mL
      • 2018-05-28 12.7 ng/mL
      • 2018-03-03 1.3 ng/mL
      • 2017-12-04 2.1 ng/mL
  • exam finding
    • 2022-09-26 ECG
      • Normal sinus rhythm
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-09-12 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal varices, F1Cb, Li-m, RCS(-), nipple sign(-)
        • Portal hypertensive gastropathy
        • Congestive duodenitis
        • Duodenal scars with bulb deformity
      • Suggestion
        • Pursue CLO test
        • OPD follow-up
    • 2022-09-01 CT - abdomen
      • Bil. diffuse HCCs s/p TACE with viable tumors.
      • No evidence of tumor rupture.
      • Partial thrombosis of left portal vein.
      • Lung and bony metastases.
    • 2022-06-30 CT - abdomen
      • Bil. diffuse HCCs s/p TACE with viable tumors.
      • Partial thrombosis of left portal vein.
      • Lung and bony metastases.
    • 2022-06-30 Knee RT
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
    • 2022-06-30 Femur RT
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
    • 2022-06-16 MRI - pelvis
      • Findings
        • Mass lesions in L5 vertebral body, right sacral ala, right iliac tuberosity, and right acetabulum. Enhancement after contrast administration.
        • Post-OP change at L4-S1. Right neuroforaminal narrowing and lateral recess effacement at L5-S1.
        • Multiple mass lesion in both hepatic lobes.
      • Impression
        • c/w HCCs with bone metastasis, involving L5, sacrum, and right pelvis
    • 2022-03-08 CT - abdomen, pelvis
      • With and without contrast enhancement CT of abdomen – whole:
        • There are diffuse enhancing tumors in both lobes of liver, s/p TACE with multiple viable tumors.
        • Unremarkable change of the spleen, pancreas and both kidneys.
        • No enlarged lymph node in the paraaortic region.
        • No ascites.
        • Post-op at L4-5 spine.
        • There is destructive bone lesion in right pelvis, paraspinal region, L4/5 level, could be due to metastasis, progression.
        • Diffuse lung emphysema.
        • Right lower lung nodule, suspected lung metastasis. Stationary.
      • Impression:
        • Diffuse HCCs s/p TACE with viable tumors.
        • Bone and spine metastasis in right pelvis, post-op at L4/5 level, progression.
        • Stationary of RLL nodule, suspected lung metastasis.
    • 2022-01-29 MRI - L-spine
      • Without- and with-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness for sagittal images and 4 mm thickness for the others) reveal:
        • A huge poorly enhancing tumor involving L5 vertebral body, mainly right part, intraspinal space and paraspinal region. S/P operation, TPSs and prosthesis, with susceptibility artifacts.
        • Progressive tumor invasion into intraspinal space and along anterolateral aspect along right iliac wing. General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis at L1-2.
        • Gr I spondylolisthesis, end-plate degeneration, disc collapse with general bulging, hypertrophic yellow ligaments, enlarged facets and superimposed tumor invasion causing moderate spinal canal stenosis and bilateral moderate to severe neuroforaminal narrowing at L4-5, more severe on right side.
        • No intramedullary lesion.
      • IMP:
        • L5 vertebral body metastasis, progressive change as compared with MRI on 20211222.
    • 2022-01-12 Patho - interveterbral disc
      • pathologic diagnosis
        • L5 spinal tumor, excision + frozen section — Metastatic hepatocellular carcinoma
      • microscopic examination
        • Microscopically, the section shows a picture of metastatic adenocarcinoma characterized by tumor cells with eosinophilic cytoplasm, bile pigment, arranged in nest or pesudoglandular pattern, hemorrhage, focal necrosis and bone invasion.
        • Immunohistochemical stains of CK7(-), CK20(-), Hepa-1(+), arginase(-) and TTF-1(-) for tumor.
        • According to clinical information and above histopathologic findings, it indicated a case of metastatic hepatocellular carcinoma, grade 2
    • 2022-01-07 CT - lung/mediastinum/pleura
      • HCC at both lobes of liver with stationary size and extension.
      • Tiny nodules at both lungs. Lung mets is favored. Stable.
    • 2022-01-06 Tc-99m MDP whole body bone scan
      • Increased activity in the L5 spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
      • Mildly increased activity in the lower T-spines. Degenerative change may show this picture. However, please follow up bone scanto rule out other possibilities.
      • A hot spot in the anterior aspect of left 2nd rib. The nature is to be determined (post-traumatic change? other nature?). Please also follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, right sternoclavicular junction and bilateral hips, compatible with benign joint lesions.
    • 2022-01-05 Chest PA/AP view
      • S/P port-A implantation.
      • Several small nodular opacity projecting at right upper lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
    • 2021-12-22 MRI - L-spine
      • suspected a large tumor at the right L5 vertebral body, right paravertebral and right perivertebral spaces.
      • herniated disc in the L4/5 disc
    • 2021-11-29 CT - abdomen, pelvis
      • Bil. diffuse HCCs s/p TACE with viable tumors. Lung and bony metastases.
    • 2021-09-07 CT - abdomen, pelvis
      • Diffuse HCCs s/p TACE with viable tumors, progression.
      • Bone metastasis, L-S.
      • Stationary RML nodule, 0.4cm. Diffuse bilateral lung emphysema.
    • 2021-06-01 CT - abdomen, pelvis
      • Liver cirrhosis with multiple HCC at both lobes of liver, the tumor extension is stationary.
      • Right lower lobe nodule. Stable.
    • 2021-04-09 KUB
      • Fecal material store in the colon.
      • Disk space narrowing and Marginal osteophyte formation at right lateral aspect of L4-5 is suspected. Please correlate with L-spine lateral view.
    • 2021-02-16 CT - abdomen, pelvis
      • LIver cirrhosis with multiple HCC s/p TACE and targeted therapy with tumor progression.
    • 2021-02-09 Abdominal Ultrasonography
      • Cirrhosis of liver
      • Hepatic tumor, multiple, probably hepatoma
    • 2020-10-20 CT - abdomen, pelvis
      • Liver cirrhosis wiht multiple HCC at both lobes of liver, in progression.
    • 2020-09-29 Abdominal Ultrasonography
      • Cirrhosis of liver
      • Hepatic tumor, multiple, probably TAE effect of hepatoma(S3)
    • 2020-08-13 CT - abdomen, pelvis
      • Bil. HCCs s/p TACE with viable tumors (up to 2.0cm, increaed tumor number but decreased tumor size).
    • 2020-04-24 Abdominal Ultrasonography
      • Liver cirrhosis
      • Hepatic tumors, favor HCC s/p TAE
    • 2020-04-23 CT - abdomen, pelvis
      • HCC s/p TACE
      • Tiny nodule at right middle lobe, intrafissural nodule is considered.
    • 2020-03-05 CT - liver, spleen, biliary duct
      • Bil. HCCs s/p TACE with viable tumors (up to 2.5cm).
      • A nodule (3.7mm) in RML.
    • 2020-01-27 KUB
      • Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Radiopaque density at left upper abdomen, probably post-TAE at left hepatic lobe. Degenerative change of the spine with marginal spur formation.
    • 2020-01-14 Abdominal Ultrasonography
      • Cirrhosis of liver
      • Hepatic tumor, probably HCC post TAE effect
      • Pleural effusion, left
    • 2019-12-25 CT - liver, spleen, biliary duct
      • Multiple HCCs in S2-3 of the liver are highly suspected.
      • Three HCCs in S7, S4/5, and S4 are also suspected.
      • Please correlate with AFP.
      • AJCC 8th edition, CT staging of HCC: T3N0Mx
    • 2017-02-07 Abdominal Echo
      • Cirrhosis of liver
      • Calcified spot of liver
  • consultation
    • 2022-01-05 Radiological Diagnosis
      • Q
        • for TAE
        • This 69-year-old male, a pt of HBV carrier with liver cirrhosis, hepatocellular carcinoma, bilateral with lung & bone mets. He was admitted due to right hip pain for 2 months ago and L-spine MRI showed suspected a large tumor at the right L5 vertebral body, right paravertebral and right perivertebral spaces.herniated disc in the L4/5 disc. We need expertise to evaluate his condition thanks!
      • A
        • According to the clinical condition and imaging findings, TAE is indicated.
    • 2020-04-22 Hemato-Oncology
      • Q
        • This 68 year-old man had medical history with HBV carrier with liver cirrhosis; PPU s/p simple closure ; GERD ; Hepatocellular carcinoma, bilateral, cT3N0M0 stage IIIa, Barcelona Clinc Liver Cancer stage B, status post 3rd Transcatheter arterial chemoembolization. Due to the 3/5 Abd CT showed Bil. HCCs s/p TACE with viable tumors (up to 2.5cm). A nodule (3.7mm) in RML. He recevied TACE of HCCs at both hepatic lobes on 20200421. So we need you evaluation and suggestion of this patient.
      • A
        • Objective
          • This 68 y/o male, a pt of HCC Dx in Dec 2019 s/p TACE x 3 on 1/7, 2/6, 4/21 20. Abd CT (3/5 20) showed Bil. HCCs s/p TACE with viable tumors (up to 2.5cm). A nodule (3.7mm) in RML. Dz in progress seems to be noted. AFP (4/20 20): 3.2
          • Albumin (4/20 20):4.2, Bil-T:0.54, PT:10.6, no ascites, no encephalopathy, Child-Pugh classification: A.
        • Suggestion
          • May do chest CT to evaluate the underlying lung mets.
          • If lung mets is confrimed, will suggest systemic therapy ( eg: Nexavar or Lenvima ) with or w/o immunotherapy wt Nivolumab (Nivo is no longer reimbursed by NHI since April 2020).
          • Palliative C/T offers little benefit to pt wt mets HCC & rarely recommended & may be the last resort of Tx.
  • surgical operation
    • 2022-01-11
      • Surgery
        • excision of malignant tumor lumbar 5
        • posterior spinal fusion with instrumentation
        • microscopy
        • fluoroscopy
        • CUSA
      • Finding
        • lumbar 5 spinal metastatic lesion from malignant tumor of liver
        • after excision of the metastatic lumbar bone invasion, mesh and autograft bone from adjacent spinal process for posterior spinal bone fusion.
        • posterior spinal instrumentation was done by L4 and S1 bilateral pedicle screws and rods.
    • 2022-01-10 Embolization (TAE) - extremity
      • TAE of RIGHT sacral tumor via right common femoral artery puncture using Seldinger technique.
      • IMP: A hypervascular tumor at RIGHT sacral region s/p TAE.
    • 2020-04-21 Embolization (TAE) - abdomen
      • TACE of bil. HCCs via right common femoral artery puncture using Seldinger technique
      • IMP: HCCs at both hepatic lobes s/p TACE.
    • 2020-02-06 Embolization (TAE) - abdomen
      • TACE of bil. HCCs via right common femoral artery puncture using Seldinger technique
      • IMP: HCCs at both hepatic lobes s/p TACE.
    • 2020-01-07 Embolization (TAE) - abdomen
      • TACE of left HCCs via right common femoral artery puncture using Seldinger technique
      • IMP: HCCs at left hepatic lobe s/p TACE.
  • radiotherapy
    • 2022-02-09 ~ 2022-02-24 - 3600cGy/12 fractions (6 MV photon) to para-L5 metastasis.
  • chemoimmunotherapy
    • 2022-10-05 - nivolumab 40mg 1hr + oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
    • 2022-09-13 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
    • 2022-08-30 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
    • 2022-08-16 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
    • 2022-08-02 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
    • 2022-07-18 - oxaliplatin 85mg/m2 135mg 2hr + leucovorin 400mg/m2 640mg 2hr D1-2 + fluorouracil 400mg/m2 640mg 10min D1-2 + fluorouracil 600mg/m2 960mg 22hr D1-2
    • 2022-06-29 - oxaliplatin 85mg/m2 139mg 2hr + leucovorin 200mg/m2 300mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
    • 2022-06-15 - oxaliplatin 85mg/m2 138mg 2hr + leucovorin 200mg/m2 300mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 970mg 22hr D1-2
    • 2022-05-30 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
    • 2022-04-28 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
    • 2022-04-15 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1-2 + fluorouracil 400mg/m2 600mg 10min D1-2 + fluorouracil 600mg/m2 980mg 22hr D1-2
    • 2022-03-31 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr D1 + fluorouracil 400mg/m2 650mg 10min D1 + fluorouracil 2800mg/m2 4600mg 46hr D1-2
    • 2022-03-18 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 650mg 2hr D1 + fluorouracil 400mg/m2 650mg 10min D1 + fluorouracil 2800mg/m2 4600mg 46hr D1-2
    • 2021-08-26 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3380mg 46hr
    • 2021-08-10 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3340mg 46hr
    • 2021-07-27 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2021-07-10 - cisplatin 40mg/m2 68mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2021-06-15 - cisplatin 40mg/m2 67mg 2hr + fluorouracil 1000mg/m2 3390mg 46hr
    • 2021-05-31 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3380mg 46hr
    • 2021-05-10 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3300mg 46hr
    • 2021-04-23 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3340mg 46hr
    • 2021-04-09 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3360mg 46hr
    • 2021-03-25 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3360mg 46hr
    • 2021-03-12 - cisplatin 40mg/m2 60mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2020-12-05 ~ 2021-02 - Stivarga (regorafenib) 160mg QD
    • 2020-06-02 ~ 2020-11 - Nexavar (sorafenib) 400mg BIDAC

==========

2022-06-30

  • A slight increase in AFP has been observed
    • 2022-03-18 16.9 ng/mL
    • 2022-03-07 12.2 ng/mL
    • 2022-01-05 11.0 ng/mL
  • The use of sorafenib and regorafenib was conducted from 2020-06 to 2021-02, nivolumab could also be considered optionally.

2022-05-31

  • This patient has been diagnosed with advanced HCC with spine mets and suspected lung mets. He underwent excision of the malignant tumour near L5 in January 2022, and a CT scan in March 2022 revealed the progressive destruction of bone at right pelvis.
  • Previously, he has received sorafenib (2020-06 ~ 2020-10), rorafenib (2020-12 ~ 2021-02), cisplatin with 5-Fu (2021-08 ~ 2021-02), and now FOLFOX4 (since 2022-03). Additionally, he had 4 TAEs on 2020-01-07, 2020-02-06, 2020-04-21, and 2022-01-10 (sacral).
  • Multikinase inhibitors and first line systemic chemotherapy have been tried. These treatments have been shown to be some effective in published studies. ( https://pubmed.ncbi.nlm.nih.gov/33869060/ ) Despite some studies showing a relatively limited efficacy of chemotherapy. ( https://bmccancer.biomedcentral.com/track/pdf/10.1186/s12885-018-5173-0.pdf )
  • There are several second line treatments for advanced HCC including cabozantinib. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8863772/ ) However, these drugs are rarely covered by national health insurance currently for advanced HCC.
  • The lab data on 2022-05-30 showed grossly normal results. No issue with active prescription.

2022-01-06

[drug interaction]

Combination use of H2 antagonist (Famotidine) and PPI (Rabeprazole) might enhance gastric acid suppression, might also increase the potential risk of Clostridioides difficile infection. Ref:

700336877

221005

  • exam findings
    • 2022-10-03 KUB
      • S/P metalic autosuture at the rectum.
      • Few calcification projecting at left renal area are noted.
    • 2022-10-03 CXR
      • Patchy opacity projecting at left upper lung zone and multiple nodular opacity projecting in both lung are noted that may be metastases. Please correlate with CT.
    • 2022-09-30 SONO - nephrology
      • Bilateral renal stones
      • Right renal cyst
    • 2022-09-09 MRI - brain
      • Left frontal tumor with mass effect. Suspected high-grade glioma.
    • 2022-09-07 CT - brain
      • an intra-axial tumor in the left frontal lobe. suspected GBM.
      • a large tumor in the left frontal region. Please correlate with contrast-enhanced study or MRI.
      • 12mm midline shift to the right side.
    • 2022-09-07 CXR
      • Patch density at LUL.
      • Multiple nodules at bil. lungs.

700704174

221005

{colon cancer}

[objective]

  • past history
    • Type 2 diabetes mellitus was diagnosed for months.
      • Kludone MR 60mg 1# po BID
      • Galvus Met 1# po BID
      • Zulitor F.C 4mg 0.5# po QN
    • Hepatitis B carrier, fatty liver for 10+ years under regular follow up at NTUH
      • Baraclude 0.5mg 1# po QDAC
    • History of operation:
      • Laparoscopic anterior resection and anastomosis-malignant on 2019/10/14.
  • lab data
    • UGT1A1 showed 1:67
    • 2022-06-15 P.jiroveci DNA (Bronchial washing) Undetectable
    • 2022-06-13 Aspergillus Ag Negative
    • 2022-06-13 Aspergillus Ag Value 0.09 Ratio
    • 2022-06-09 MTBC PCR NOT DETECTED
    • 2022-06-09 MTBC PCR Value <131 CFU/ml
    • 2022-06-06 Aspergillus Ag Negative
    • 2022-06-06 Aspergillus Ag Value 0.11 Ratio
    • 2022-06-06 Anti-ds DNA Antibody <0.5 IU/ml
    • 2022-06-06 Anti-cardiolipin-IgM 2.1 MPL U/mL
    • 2022-06-06 Anti-Cardiolopin IgG 0.8 GPL-U/mL
    • 2022-06-06 Anti-ENA Sm 2.0 EliA U/ml
    • 2022-06-06 Anti-ENA RNP 0.5 EliA U/ml
    • 2022-06-06 Anti-ENA(Jo-1) EliA U/ml
    • 2022-06-06 Anti Jo-1 antibody <0.3 EliA U/ml
    • 2022-06-06 Anti-ENA (Scl-70) EliA U/ml
    • 2022-06-06 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
    • 2022-06-06 Anti ENA(Ro,La) EliA U/ml
    • 2022-06-06 Anti-ENA SS-A(Ro) 0.3 EliA U/ml
    • 2022-06-06 Anti-ENA SS-B(La) <0.3 EliA U/ml
    • 2022-06-06 PR3 Negative IU/ml
    • 2022-06-06 PR3 Value <0.2 IU/ml
    • 2022-06-06 MPO Negative
    • 2022-06-06 MPO Value <0.2 IU/ml
    • 2022-06-06 ANA Negative
    • 2022-06-04 Cryptococcus Ag Negative
    • 2022-06-04 RF <10 IU/mL
    • 2022-06-03 LA1 39.5 sec
    • 2022-06-03 LA2 34.0 sec
    • 2022-06-03 LA1/LA2 ratio 1.0
    • HbA1c
      • 2022-06-30 HbA1c 6.4 %
      • 2022-04-07 HbA1c 6.9 %
      • 2022-01-10 HbA1c 6.5 %
      • 2021-11-11 HbA1c 8.2 %
      • 2021-09-07 HbA1c 8.9 %
      • 2021-04-12 HbA1c 7.5 %
      • 2021-01-14 HbA1c 8.3 %
      • 2020-10-22 HbA1c 6.6 %
      • 2020-07-31 HbA1c 7.2 %
      • 2020-05-07 HbA1c 8.1 %
      • 2020-02-14 HbA1C 7.7 %
      • 2019-10-06 HbA1C 10.7 %
    • CEA
      • 2022-06-24 CEA 7.40 ng/mL
      • 2022-05-24 CEA 4.26 ng/mL
      • 2022-04-15 CEA 2.44 ng/mL
      • 2022-03-18 CEA 1.79 ng/mL
      • 2022-02-16 CEA 2.21 ng/mL
      • 2022-01-19 CEA 2.04 ng/mL
      • 2021-12-22 CEA 2.49 ng/mL
      • 2021-12-03 CEA 2.57 ng/mL
      • 2021-11-16 CEA 3.33 ng/mL
      • 2021-10-20 CEA 3.76 ng/mL
      • 2021-09-28 CEA 2.28 ng/mL
      • 2021-09-07 CEA 3.19 ng/mL
      • 2021-07-16 CEA 2.98 ng/mL
      • 2021-06-24 CEA 2.27 ng/mL
      • 2021-06-02 CEA 3.22 ng/mL
      • 2021-04-20 CEA 3.43 ng/mL
      • 2021-03-09 CEA 8.40 ng/mL
      • 2021-02-05 CEA 6.039 ng/ml
      • 2020-11-06 CEA 1.313 ng/ml
      • 2020-08-07 CEA 0.761 ng/ml
      • 2020-04-15 CEA 1.183 ng/ml
      • 2019-12-31 CEA 1.97 ng/mL
      • 2019-10-04 CEA 2.38 ng/mL
  • exam finding
    • 2022-09-29 CXR
      • Linear and nodular infiltration over both lung are noted. please correlate with clinical condition and CT to R/O lypmphangitic carcinomatosis.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • 2022-07-29 Whole body PET scan
        1. In comparison with the previous study on 2021/02/24, the previous FDG avid lesion in the C7 spine is a little less evident. However, the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident. Multiple metastatic lesions should be considered first.
        1. Increased FDG uptake in the left aspect of mandible. Osteonecrosis may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
        1. Increased FDG uptake in the region about prostate. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
        1. Increased FDG uptake in the left shoulder, compatible with arthritis.
    • 2022-06-16 Nerve Conduction Velocity, NCV; Electromyography, EMG
      • Finding (Motor nerve conduction study)
        • Normal distal latency with reduced MNCV and normal CMAP amplitude in the bilateral median nerves.
        • Normal distal latency with reduced MNCV and normal CMAP amplitude in the bilateral ulnar nerves
      • Conclusion
        • Sensorimotor demyelinating polyneuropathy with secondary axonal loss (suspect chemotherapy superimposed with diabetes related). Please correlate with the clinical presentations.
    • 2022-06-09 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/03/10, the lesion in the lower C-spine is slightly more evident, compatible with bone metastasis in slight progression.
      • No prominent change is noted in other bone lesions. Suspected benign lesions in bilateral rib cages, mandible, lower L-spine, bilateral shoulders and knees.
    • 2022-06-10 Patho - lung transbronchial biopsy
      • Lung, LUL, bronchoscopic biopsy — metastatic adenocarcinoma, consistent with colorectal origin
      • Sections show bronchial mucosa with neoplastic glandular cells infiltrating in muscular layer.
      • The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and TTF-1(-). The results are consistent with metastatic colorectal adenocarcinoma.
    • 2022-06-08 Body fluid cytology - bronchial washing
      • Smears show histiocytes, benign bronchial cells and clusters of atypical hyperchromatic cells with increased N/C ratio.
      • Malignancy is suspected.
      • Please correlate with the clinical presentation.
    • 2022-06-08 Patho - esophageal biopsy
      • EC junction, biopsy — squamous hyperplasia and moderate chronic inflammation.
    • 2022-06-08 MRI - C-spine
      • IMP: Bony metastasis at C7 vertebral body, causing intrapsinal and paraspinal involvement as described. Stationary or mild progression as compared with MRI on 20220311.
    • 2022-06-08 Esophagogastroduodenoscopy (EGD)
      • Diagnosis
        • Reflux esophagitis LA grade A
        • Suspected Barett’s esophagus, s/p biopsy
        • Superficial gastritis, s/p CLO test
        • Duodenal ulcer scar, bulb
      • Suggestion
        • Pursue the result of pathology report and CLO test
    • 2022-06-08 Bronchoscopy
      • Bronchoscopic diagnosis:
          1. LUL acute bronchitis
          1. No endobronchial lesion
          1. Chronic hypertrophic rhinitis
    • 2022-06-07 CT - abdomen, pelvis
        1. Post-op at the colon. Rim enhanced nodule (1.6cm) in left paracolic region, stationary.
        1. Suspected adrenal metastasis.
        1. Diffuse bilateral lung interstitial infiltrates, suspected lymphangitic carcinomatosis.
    • 2022-05-31 CT - lung
      • pulmonary lypmphangitic carcinomatosis, metastatic adrenal tumors, and metastatic Lt supraclavicular and Rt paratracheal LNs, in progression compared with CT on 2022/03/09.
    • 2022-05-24 Walking 6 minutes
      • Conclusion
        • Obstructive ventilatory impairment with both large and small airway involved,resulting dynamic hyperinflation.
        • Fluctuated O2 saturation at resting, with early and prolonged desaturation during exercise, with SaO2 91% nadir
        • during exercise. Emphysema or DPLD with SAD was considered.
      • Suggestion:
          1. Check and treat underlying small airway diseases
          1. May try bronchodialtor targeting the small airways if symptomatic
          1. Exercise training
          1. Breahing control wtih purse-lip breathing during exercise
          1. f/u HRCT
          1. f/u 6-12 months later
    • 2022-05-24 Pulmonary Function Test, PFT
      • Moderate obstructive ventilatory impairement, with both large and small airway involved with partial reversibility
      • Low IC, TLC
      • No hyperinflation, no air-trapping.
      • Normal diffusion capacity
      • High airway resistance
      • Favor COPD, mainly chronic bronchitis
    • 2022-05-10 SONO - articular peripheral soft tissue
      • Impression And Suggestions:
        • Mild left shoulder supraspinatus tendiniti
        • Pain at terminal ranges of motion, compatible with left shoudler adhesive capsulitis.
    • 2022-05-09 CXR
      • Linear infiltration over both lung are noted. please correlate with clinical symptom to rule out inflammatory process.
    • 2022-05-06 SONO - abdomen
      • Diagnosis
          1. Fatty liver, mild
          1. Renal cyst, left
          1. pancreatic body masked by gas.
      • Suggestion
          1. encourage exercise and diet adjustment.
    • 2022-03-11 MRI - C-spine
      • Findings
          1. General bulging disc with central disc protrusion, posterolateral osteophytes and enlarged facets causing spinal canal stenosis and bilateral neuroforaminal narrowing at C3-4-5-6, most severe at C5-6.
          1. Collapse of C7 vertebral body with T1- and T2-hypointensity and poor enhancement. Similar intensity also noted in its spinous process, indicating bony metastasis. Posterior bony displacement causing spinal canal stenosis and cord compression also noted.
          1. No intramedullary abnormality.
      • IMP:
        • Bony metastasis at C7 vertebral body. Stationary as compared with MRI on 20210726.
    • 2022-03-10 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2021/11/24, no prominent change is noted in the lesion in the lower C-spine, compatible with bone metastasis in stationary status.
    • 2022-03-09 CT - abdomen, pelvis
      • Findings
          1. Prior CT identified a rim enhancing lesion and fat component measuring 1.9 x 1.7 cm in left paracolic gutter space is noted again, stable in size and feature. Benign lesion is highly suspected. Follow up is indicated.
          1. Prior CT identified One enlarged node measuring 1.2 cm in aortocaval space is not noted in the current CT.
          1. Adenoma 1.3 cm and hyperplasia in left adrenal gland show stationary.
          1. A renal cyst measuring 0.9 cm in left upper pole is noted.
      • Impression
        • There is no evidence of tumor recurrence.
    • 2021-11-24 Tc-99m MDP whole body bone scan
      • The lesion of increased tracer uptake in a lower C-spine comes to less evident compared to the previous study on 2021-07-27, and no new lesion of increased tracer uptake is noted, suggesting partial response to current therapy.
    • 2021-11-23 MRI - C-spine
        1. C7 metastasis, seems stationary
        1. Small C4/5/6 central HIVDs with combined spinal canal stenoses.
    • 2021-11-19 CT - abdomen, pelvis
      • Findings
          1. Prior CT identified a rim enhancing lesion and fat component measuring 1.9 x 1.7 cm in left paracolic gutter space is noted again, stable in size and feature. Benign lesion is highly suspected. Follow up is indicated.
          1. One enlarged node measuring 1.2 cm in aortocaval space is noted.
          1. Adenoma 1.3 cm and hyperplasia in left adrenal gland show stationary.
          1. A renal cyst measuring 0.9 cm in left upper pole is noted.
      • IMP:
          1. One enlarged node 1.2 cm in aortocaval space is noted.
    • 2021-08-25 SONO - abdomen
      • fatty liver, mild
    • 2021-07-28 CT - abdomen, pelvis
        1. Prior CT identified a rim enhancing lesion and fat component measuring 1.9 x 1.7 cm in left paracolic gutter space is noted again, stable in size and feature. Benign lesion is highly suspected. Follow up is indicated.
        1. Prior CT identified several enlarged nodes in para-aortic space and para-cava space are not noted again that may be metastatic nodes S/P C/T show complete response.
    • 2021-07-27 Tc-99m MDP whole body bone scan
        1. Prominently increased activity in a lower C-spine. Bone metastasis may show this picture.
        1. Mildly increased activity in the lower L-spines. Degenerative change is more likely. Please correlate with other imaging modalities for further evaluation.
        1. Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
        1. Increased activity in bilateral shoulders and knees, compatible with benign joint lesions.
    • 2021-07-26 MRI - C-spine
      • indication: Sigmoid cancer with lymph node metastasis s/p Laparoscopic anterior resection and anastomosis-malignant on 2019/10/14, pT3N2bM0, stage IIIC s/p adjuvant chemotherapy with tumor recurrence and C7 spine metastasis, rcTxN0M1a, r-staging IVA
      • Bony metastasis at C7 vertebral body.
    • 2021-03-23 SONO - abdomen
      • probably fatty liver
    • 2021-03-17 MRI, C-spine:
      • bony spinal canal stenosis in the middle and lower C-spine.
      • degenerative change in the middle and lower C-spine disc spaces
      • a heterogeneous enhancing tumor at C7 vertebral body.
      • degerative change at lower C-spine facet joints.
    • 2021-03-09 sigmoidoscopy:
      • negative finding up to D-colon.
      • no evidence of local recurrence.
    • 2021-02-27 whole body PET scan:
      • a glucose hypermetabolic lesion in the rectal region, probably tumor recurrence.
      • glucose hypermetabolic lesion at the C7 spine, probably tumor with distant metastasis.
      • increased FDG uptake in bilateral pulmonary hilar regions and the right shoulder, benign change is more likely.
      • s-colon cancer s/p treatment with tumor recurrence and C7 spine metastasis, rcTxN0M1a, r-staging IVA (AJCC 8th edi.)
    • 2021-02-22 CT, abdomen:
      • tumor seeding in left paracolic gutter space is suspected. the differential diagnosis include epiploic appendagitis or omentum infarction.
      • metastatic nodes in para-aortic space and para-cava space are suspected.
    • 2020-05-07 CT, abdomen, pelvis:
      • colon cancer s/p operation. focal fat stranding at LUQ without interval change.
      • left adrenal nodule (1.3cm) without interval change.
    • 2020-05-07 sigmoidoscopy: no evidence of recurrence
    • 2019-10-16 patho:
      • sigmoid colon, laparoscopic sigmoid colectomy - adenocarcinoma
      • lymph node, mesocolic, dissection - positive for tumor metastasis (8/18) with extracapsular extension (6/8)
      • AJCC pathologic stage - pT3N2bMx, stage IIIC at least B.
    • 2020-01-16 CT, abdomen:
      • colon cancer s/p operation. focal fat stranding at LUQ.
      • left adrenal nodule (1.3cm).
    • 2019-10-14 laparoscopic anterior resection and anastomosis-malignant, finding:
      • sigmoid cancer 533cm near D-S junction with nearly total obstruction
      • splenic flexure was fully mobilized
    • 2019-10-03 colonofiberoscopy: an ulcerative lesion with lumen narrowing at 30 cm to 40 cm from anal verge and biopsy was done. impression: suspicion of sigmoid colon tumor.
    • 2019-10-03 CT, abdomen:
      • wall thickening of sigmoid colon, 4.4 cm in length, with perifocal fat stranding.
      • sigmoid colon cancer T3N1MX.
    • 2019-09-20 screening for malignant neoplasm, colon: stool occult blood test positive
  • consultation
    • 2022-10-05 Oral and Maxillofacial Surgery
      • Q
        • for osteonecrosis of jaw evaluate
        • This 58-year-old man patient is a case of adenocarcinoma of sigmoid with obstruction post laparoscopic anterior resection pT3N2bM0 stage IIIC for twelfth FOLFOX6 adjuvant chmotherapy; ECOG: 1, and Xgavex therapy, now, his tooth loss one, so we need your help for osteonecrosis of jaw evaluate. Thank you.
      • A
        • The exam will be arranged today.
    • 2021-09-13 Metabolism and Endocrinology
      • Q
        • This 57-year-old man patieitn is a case of Sigmoid cancer with LN metas s/p Laparoscopic, pT3N2bM0, stage IIIC s/p C/T with recurrence and boneas, rcTxN0M1a, r-staging IVA. He was admitted for chemotherapy with Avastin(C8)/FOLFIRI(C5D1) from 2021/09/09~2021/09/11. This time, for Type 2 diabetes mellitus with OHA control (Kludone MR 60mg 0.5# po QDAC, Galvus Met 1# po BID, Tulip F.C 20mg 1# po QD), But, HbA1c progression(20210412 showed 7.5%, 20210907 showed 8.9%). Now, for evaluate Type 2 diabetes mellitus with OHA control therapy. Thank you.     
      • A
        • S: We were consulted for blood sugar control.
        • O
          • BH: 163 cm, BW: 63 Kg
          • Diet: DM diet 1800 kcal/day
          • Medication in OPD: Kludone 1# BID, GalvusMet 1# BID
          • Medication during hospitalization: same as above
          • PE: no cushingoid appearance
          • Na: 140, K: 4.0
          • AST/ALT: 13/7
          • BUN/Cr: 13/0.66 (eGFR: 132.23)
          • F/S:
            • Date 210909 210910
            • QDAC - 253
            • QLAC - -
            • QNAC 246
            • HS -
          • Blood glucose: 238 mg/dL
          • HbA1c: 7.5 -> 8.9
          • Urine ACR: 0.03
          • OPH OPD: in LMD (no record)
          • ACTH/cortisol (8am): 14.2/10.79 (2020/05)
          • PRA/aldo: 0.23/100 (2020/05)
          • Urine VMA/catecholamine: within normal range (2020/05)
          • DHEA-S: 198 (2020/05)
          • Testosterone: 343.59 (2020/05)
          • Abd. CT: (2021/07/28)
              1. Adenoma 1.3 cm in left adrenal gland shows stationary.
              1. Hyperplasia of left adrenal gland is also noted.
        • A:
            1. Type 2 DM, poor control
            1. Left adrenal adenoma and hyperplasia
            1. Recurrent sigmoid CA
        • Suggestions:
            1. Check F/S TIDAC + HS (please confirm timed quantification of each meal)
            1. DC GalvusMet, Kludone
            1. Give Apidra 3U TIDAC and adjust with correction scales
            • F/S < 080, Apidra hold
            • F/S 081~100, Apidra -2U
            • F/S 201~250, Apidra +1U
            • F/S 251~300, Apidra +2U
            • F/S > 300, Apidra +3U
            1. Give Tresiba 8U HS and adjust as below
            • F/S QDAC < 100 (for 1 day), Tresiba -2U
            • F/S QDAC > 150 (for consecutive 3 days), Tresiba +2U (each adjustment is for the day)
            1. Adrenal incidentaloma survey is not feasible for now (steroid use on 20210909 and will be discharged on 20210912). We will arrange in OPD later.
            1. Adrenal gland malignancy or metastasis should be ruled out: check DHEA-S
            1. Meta-OPD F/U, contact us if any problem
    • 2021-04-21 Neurology
      • Q
        • Vertigo was noted since 2021/3 post chemotherapy, we need your help for further management, thanks a lot.
      • A
        • S
          • Persistent transient vertigo episodes aggravate by lying down or fast head movement and relieved by avoiding head movement for about 1 month. Minimal tinnitus without ear infection also present. Headache, limb weakness or clumsiness was denied. Vertigo association with body position change is also denied
        • O
          • Consciouenss: clear, E4V5M6
          • Language: normal
          • Visual field: normal
          • EOM: free , no nystagmus
          • HINTs exam: intact
          • Pupil: 3.0/3.0 mm, Light reflex: +/+
          • Face: symmetrical
          • Muscle power: full
          • DTR: ++/++
          • Coordination: FNF & HKS intact, no truncal titubation
          • BabinskI sign: down/down
          • Sensory: decrease pinprick distal finger and toes
          • Gait: intact
        • Impression:
          • BPPV, suspected chemotherapy side effect
        • Plan
            1. Meclizine 25mg 1# BID or Diphenidol 25mg 1# tid
            1. May arrange MRA brain with/without contrast to rule out brain metastasis
    • 2021-04-20 ENT
      • Q
        • Vertigo was noted since 2021/3 post chemotherapy, we need your help for further management, thanks a lot.
      • A
        • S
          • Vertigo for 1 month.
          • Spinning(+), imbalance(-) neck soreness(-), headache(-) hearing loss (-) tinnitus(+, mild, R, jijijiao) Recent URI(-)
          • Duration: secs
          • Aggravates: when lying down
          • Reliever : remain still
          • Association : nausea(-) vomiting(-)
        • PE
          • Ear drum: intact
          • VFT
            • No spontaneous, positional, positioning nystagmus
            • finger nose finger: ok
            • Rapid alternative movement: ok
            • Romberg test: ok
            • Steping test: ok
            • Tandem gait: ok
          • Dix-Hallpike test: left geotropic torsional nystagmus s/p Epley maneuver
        • Imp: L p-BPPV
        • Plan:
            1. Educated patient about BPPV
            1. ENT OPD f/u if s/s persist
    • 2021-03-16 Oral and Maxillofacial Surgery
      • Q
        • Now, for Xgavex therapy, for evaluate tooth for prevention ONJ. Thank you.
      • A
        • S
          • After examining the patient’s dental condition based on panoramic film and intraoral examination, retained root of tooth 16 and apical lesion of tooth 37 was noted.
        • O:
            1. Retained root of tooth 16
            1. Apical periodontitis of tooth 36 with percussion
            1. Benign looking calcification of right mandibluar angle
        • A:
            1. Retained root of tooth 16
            1. Chronic apical lesion of tooth 36
        • P:
            1. Explain the findings to the patient
            1. Suggest dental extraction of retained root of tooth 16 and dental root canal treatment of tooth 36
    • 2021-03-15 Dentistry
      • Q
        • Now, for Xgavex therapy, for evaluate tooth for prevention ONJ. Thank you.
      • A
        • Intra-oral examination, a gum boil over lower left molar area is noted .
        • Further root canal therapy or extraction mightbe necessary , suggest consult the oral sergery section for sure.
    • 2021-03-15 Neurosurgery
      • Q
        • Whole body PET scan on 2021/02/24 showed: 1. A glucose hypermetabolic lesion in the rectal region, probably tumor recurrence. 2. Glucose hypermetabolic lesion at the C7 spine, probably tumor with distant metastasis. Now, for evaluate C7 spine metastasis therapy. Thank you.
      • A
        • Suggest arrange C-spine MRI with and without enhancement for further evaluation.
        • Radiotherapy for the suspected metastatic lesion of cervical spine is also the treatment of option.
  • chemoimmunotherapy
    • 2022-08-25 - irinotecan 120mg/m2 180mg 90min + leucovorin 300mg/m2 450mg 2hr + fluorouracil 300mg/m2 450mg 10min + fluorouracil 2000mg/m2 3000mg 46hr
    • 2022-08-02 - irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + fluorouracil 2400mg/m2 3700mg 46hr
    • 2022-07-11 - bevacizumab 5mg/kg 300mg + irinotecan 150mg/m2 220mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3800mg 46hr
    • 2022-06-15 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-11-19 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-10-26 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-10-04 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-09-09 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-08-18 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-07-23 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-06-30 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-06-07 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-05-13 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-04-20 - bevacizumab 5mg/kg 400mg + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-04-02 - bevacizumab 5mg/kg 400mg + irinotecan 120mg/m2 230mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-03-18 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr
    • 2020-04-13 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 678mg 2hr + fluorouracil 2800mg/m2 4748mg 40hr
    • 2020-03-30 - oxaliplatin 85mg/m2 143mg 2hr + leucovorin 400mg/m2 675mg 2hr + fluorouracil 2800mg/m2 4737mg 40hr
    • 2020-03-16 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 678mg 2hr + fluorouracil 2800mg/m2 4750mg 40hr
    • 2020-03-02 - oxaliplatin 85mg/m2 143mg 2hr + leucovorin 400mg/m2 673mg 2hr + fluorouracil 2800mg/m2 4700mg 40hr
    • 2020-02-17 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 669mg 2hr + fluorouracil 2800mg/m2 4684mg 40hr
    • 2020-02-03 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 40hr
    • 2020-01-15 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 669mg 2hr + fluorouracil 2800mg/m2 4600mg 40hr
    • 2021-04-02 ~ undergoing - Xgeva (denosumab) 120mg SC (self-paid)
    • 2021-12-02 ~ 2022-06-13 - Xeloda (capecitabine) 500mg BID
    • 2021-03-18 ~ 2021-11-19 - FOLFIRI, + avastin (bevacizumab) since 2021-04-02
    • 2019-11-04 ~ 2020-04-13 - FOLFOX (7 times)

==========

[not posted?]

  • no IHC stains (MSI, MMR) from patho report, no KRAS/NRAS/BRAF/HER2/NTRK found.
  • adjuvant treatment with FOLFOX 6 months s/p laparoscopic anterior resection.
  • the elevated CEA and CA199, together with PET and MRI imaging in Feb~Mar 2021 showed spine metastasis. the startup FOLFOX might not work anymore.
  • shift to FOLFIRI + bevacizumab + denosumab since Apr 2021. the former two are 2nd-line treatment and the last one is for the bone mets.
    • prior to the use of denosumab, dentist has been consulted for evaluating osteonecrosis of the jaw, ONJ.
  • patients with the UGT1A1 7/7 genotype may be at increased risk for developing GI toxicity and myelosuppression. dose reduction should be considered in this setting.
  • the treatments are followed the NCCN guidelines, no issue found.

2022-10-05

  • The patient has been experiencing coughing with sticky sputum and shortness of breath over the past week. He is currently being treated with imipenem-cilastatin. A CXR performed on 2022-09-29 revealed infiltration of both lungs and blunted costal-phrenic angles. The results of previous PET and CT images suggested the presence of pulmonary lymphomatic carcinomatosis.
  • Blood sugar levels during this hospital stay remained acceptable, however HbA1c slightly increased during the last quarter (2022-09-22 7.0% <- 2022-06-30 6.4%).
  • There has been a loss of more than 15 kilograms in the last five months (2022-10-04 49.7kgw <- 2022-05-06 66kgw; 2022-10-05 albumin 2.9g/dL). An increase in intake should be beneficial for this patient.

2022-08-04

  • 2022-07-29 Whole body PET scan showed the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident.

  • In recent months, CEA lab data showed an increasing trend

    • 2022-07-21 CEA 8.47 ng/mL
    • 2022-06-24 CEA 7.40 ng/mL
    • 2022-05-24 CEA 4.26 ng/mL
    • 2022-04-15 CEA 2.44 ng/mL
    • 2022-03-18 CEA 1.79 ng/mL
  • F/S blood sugar level were 200 +- 20 mg/dL, body weight loss: 57kg <- 66kg (2022-06), empagliflozin 25mg QDPC or canagliflozin 100mg QDAC might be an optional add-on.

2022-07-12

  • HbA1c trend shows that blood sugar level control is improving.
    • 2022-06-30 6.4 %
    • 2022-01-10 6.5 %
    • 2021-11-11 8.2 %
    • 2021-09-07 8.9 %
    • 2019-10-06 10.7 %
  • TPR, BP, SpO2 were stable except for asymptomatic slight tachycardia (114 pulse/min).
  • No issue with active prescription.

[visiting the patient]

  • I visited the patient at approximately 13:25 2022-07-12.
  • The patient stated:
      1. Despite various visits to the orthopaedic and rehabilitation OPD, the pain in the left shoulder and arm has not improved. (morphine mitigates the pain)
      1. It is difficult for him to sleep well at night because he feels hot. With earlier chemotherapy, this is not the case.
      1. During chemotherapy, he still feels nauseated, but after returning home, the nausea has improved and is tolerable.
      1. He has nonproductive coughs, and sometimes feels “stagnant” when breathing, and he cannot speak too fast or too long.
      1. He feels that his physical strength is not as good as before, so he does not want to exercise or even walk as he once did.
      1. When morphine was used at night, the pain became less severe and the sleep became more restful. He asked if it would be possible overdose or become addicted to morphine by taking it.
  • I explained to the patient:
      1. Morphine is not likely to cause overdose or addiction based on the current dosage and usage.
      1. I encourged the patient to maintain a regular exercise regimen in order to keep muscle strength.
  • No other medication-related questions raised by the patient.
  • It appeared that his lung function was gradually deteriorating. Regular follow-up might be necessary.

2021-07-26

[colon cancer]

  • adjuvant treatment with FOLFOX 6 months s/p laparoscopic anterior resection on 2019-10-14 inhibited the tumor for 1+ year.
  • the elevated CEA and CA199, together with PET and MRI imaging in Feb~Mar 2021 showed spine metastasis, meaning the startup FOLFOX might not work anymore.
  • shift to FOLFIRI + bevacizumab + denosumab since Apr 2021. the former two are 2nd-line treatment and the last one is for the bone mets.
    • prior to the use of denosumab, dentist has been consulted for evaluating osteonecrosis of the jaw, ONJ.
    • the slight elevated CEA and CA199 in 2021 July probably hinted a decreasing response to the current treatment.
  • MMR proficient, pembrolizumab or novolumab might not be indicated.
  • EGFR(+), cetuximab or panitumumab might be indicated.
  • BRAF V600E lab data not found, vemurafenib, dabrafenib, encorafenib might not be indicated.
  • regorafenib might be indicated for the next-line treatment (after having 5-FU, OX, IRI based chemo regimen and anti-VEGF agent while KRAS wild type, under the scope of benefits of NHI).

[type 2 DM]

  • lab data showed serum glucose (AC) ranging 142~191mg/dL, HbA1c 6.6~8.3% since May 2020.
  • prescribed anti-DM agents such as metformin, gliclazide, vildagliptin were listed in PharmaCloud, could be set as ‘self-carried’ items if needed.

[dyslipidemia]

  • triglyceride, cholesterol total lab data were within normal range these months, no special issue found.

[assessment]

  • no IHC stains (MSI, MMR) from patho report, no KRAS/NRAS/BRAF/HER2/NTRK found.
  • adjuvant treatment with FOLFOX 6 months s/p laparoscopic anterior resection.
  • the elevated CEA and CA199, together with PET and MRI imaging in Feb~Mar 2021 showed spine metastasis. the startup FOLFOX might not work anymore.
  • shift to FOLFIRI + bevacizumab + denosumab since Apr 2021. the former two are 2nd-line treatment and the last one is for the bone mets.
    • prior to the use of denosumab, dentist has been consulted for evaluating osteonecrosis of the jaw, ONJ.
  • the treatments are followed the NCCN guidelines, no issue found.

2021-03-15

[felt fatigue in prior chemo]

  • visiting the patient at 09:47 on 2021-03-15, he is wide awake, this patient has not been administrated chemo regimen yet since this admission, in prior to the chemo course, consultations for C7 spinal segment and ONJ are arranged (based on his PET scan outcome).

  • he says he felt fatigue after chemo been started 2-3 days in the prior course.

  • HbA1c 8.3% and serum glucose (AC) 191mg/dL reported on 2021-01-14, no newer data available, could be followed up if necessary.

700856538

221005

  • lab data
    • 2022-03-18 EGFR基因突變檢測
    • 2022-03-18 EGFR specimen number S2022-3327
    • 2022-03-18 EGFR G719X not detected
    • 2022-03-18 EGFR Exon19 del detected
    • 2022-03-18 EGFR S768I not detected
    • 2022-03-18 EGFR T790M not detected
    • 2022-03-18 EGFR Exon20 ins not detected
    • 2022-03-18 EGFR L858R not detected
    • 2022-03-18 EGFR L861Q not detected
    • 2022-03-16 PD-L1 (22C3) specimen number S2022-3327
    • 2022-03-16 PD-L1 (22C3) TPS < 1%
    • 2022-03-14 Anti-HCV Nonreactive
    • 2022-03-14 Anti-HCV Value 0.05 S/CO
    • 2022-03-14 HBsAg Nonreactive
    • 2022-03-14 HBsAg (Value) 0.34 S/CO
    • 2022-03-14 Anti-HBs 23.31 mIU/mL
    • 2022-03-14 P.jiroveci DNA (Quality) Positive
    • 2022-03-09 Aspergillus Ag Value 0.15 Ratio
  • exam finding
    • 2022-09-28 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/07/07, the lesion in the lower T-spine is a little less evident, indicating response to current therapy or benign lesion in resolution.
      • Suspected benign lesions in the skull, bilateral rib cages, L5-sacrum junction, bilateral shoulders, hips, knees, and right foot.
    • 2022-09-27 CT - chest
      • Dx: Right middle lobe Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1,
      • Findings
        • Lungs:
          • s/p RML lobectomy with surgical staple line over anterior lung region, along anterior major fissure.
          • a 6mm nodule in LUL and a 3mm nodule in RUL.
        • Mediastinum and hila: no enlarged LN or mass.
        • Vessels:
          • Aorta: normal appearance of thoracic aorta and central pulmonary arteries.
          • Heart: normal in size of cardiac chambers.
        • Pleura: a small loculated effusion along anterior Rt major fissure
        • Chest wall and visible lower neck: unremarkable.
        • Visible abdominal contents:
          • normal appearance of gallbladder. no focal lesion in visible portion of the liver, spleen, both adrenal glands, pancreas, and kidney. no enlarged lymph node.
        • Visualized bones: no destructive lytic or blastic change even at T9 spinal process depicted on 2022/03/09 MRI exam.
          • nonenhanced axial brain CT shows: no space taking in the brain.
      • Impression:
        • post op change in Rt lung. LUL 6mm nodule and RUL 3mm nodule.
    • 2022-09-26 CXR
      • increased density over of Rt hilar shadow s/p RML lobectomy with surgical staple line over perihilar lung region
      • Rt phrenic peak
    • 2022-07-07 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/03/03, the lesion in the lower T-spine is a little more evident.
      • Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
    • 2022-07-06 MRI - brain
      • no evidence of brain metastasis.
    • 2022-07-05 CT - chest
      • post op change in Rt lung. no abnormal new nodule or mass in both lungs.
    • 2022-03-09 MRI - T-spine
      • Bony metasatsis at spinous process of T9 vertebral body. (due to a lung cancer in RLL?)
    • 2022-03-08 Patho - lung total/lebe/segmental
      • Pathologic Diagnosis:
        • Lung, right, middle lobe, lobectomy —- Adenocarcinoma, poorly differentiated
        • Lung, right, upper lobe, wedge resection —- Adenocarcinoma, by direct invasion
        • Lymph node, group No.2+4, lymphadenectomy —- Negative for malignancy (0/2)
        • Lymph node, group No.7, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
        • AJCC 8th edition pTNM Pathology stage: pStage IVA, pT3N0M1a
      • Microscopic Description
        • Tumor Focality:Separate tumor nodules of same histopathologic type (intrapulmonary metastases) in same lobe
        • Histologic Type (select all that apply): Invasive adenocarcinoma, solid predominant (60 %);
          • The immunohistochemical stains reveal TTF-1(+), CDX2(focal weak +), CD56(focal +), and p40(-).
          • Other subtypes present (specify subtype(s), may also include percentages): acinar: 30%; micropapillary: 10%.
        • Histologic Grade: G3: Poorly differentiated
        • Spread Through Air Spaces (STAS): Not identified
        • Visceral Pleura Invasion: Present (PL2)
        • Lymphovascular Invasion (select all that apply): Present, Lymphatic and Venous
        • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
        • Margins (select all that apply): All margins are uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin (centimeters): 0.2 cm
          • Specify closest margin:
            • RML: bronchial resection margin
            • RUL: wedge resection margin: 0.3 cm
        • Treatment Effect: No known presurgical therapy
        • Regional Lymph Nodes: group 2+4: 0/2; group 7: 0/1; group 9: 0/1
        • Extranodal Extension: Not identified
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply): absent
            • Primary Tumor (pT): pT3: separate tumor nodule(s) in the same lobe as the primary
            • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case): pM1a: Separate tumor nodule(s) in contralateral lobe; tumor with pleural or pericardial nodules or malignant pleural (or pericardial) effusion
        • Additional Pathologic Findings (select all that apply): None identified
    • 2022-03-04 MRI - brain
      • Brain metastases, right frontal periventricular white matter and right frontal cortex.
    • 2022-03-04 Cardiopulmonary Exercise Testing
      • Conclusion
        • submaximal exercise
        • low exercise capacity (VO2 52%, WR 77%)
        • low stroke volume response during exercise
        • slow HR response
        • small airway disease (FVC 86%, FEV1 77%, MMEF 53%)
        • normal respiratory muscle strength (MIP 84%, MEP 96%)
      • Suggestion:
        • treat underlying condition
        • survey and treat cardiac function
        • small airway disease, give bronchodilator
        • arrange pulmonary rehab with exercise training
    • 2022-03-03 Tc-99m MDP whole body bone scan
      • Prominently increased activity in the lower T-spine. The nature is to be determined. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
      • Mildly increased activity in the L5-sacrum junction. Degenerative change may show this picture.
      • Some faint hot spots in the skull and bilateral rib cages (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
    • 2022-03-02 Patho - lung transbronchial biopsy
      • Lung, RML, CT-guide biopsy — adenocarcinoma, poorly differentiated
      • Sections show solid nests and acinar glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
      • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(+), CDX2(focal +), p40(-), and CD56(focal +). The results are supportive for the diagnosis.
    • 2022-03-02 CXR
      • A well defined mass (36 mm) over RML, favor a malignant tumor
      • Rt apicolateral pneumothorax s/p transthoracic needle biopsy of RML nodule.
    • 2022-02-07 CT - abdomen, pelvis
      • History and indication:
        • A case of rectal carcinoid (NET) s/p TAMIS local excision
      • Findings
        • A pathcy density (4.5cm) at RML with pericardial invasion. Some nodules at bil. lungs.
        • S/P rectal operation.
        • Right renal angiomyolipoma (3.0cm).
        • Left adrenal nodule (7mm).
        • Right liver cyst (4mm).
        • Metastases in spine.
        • Normal appearance of spleen, pancreas.
        • Normal appearance of gallbladder.
        • Patency of portal vein.
        • No ascites, nor enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
      • Imaging Report Form for Lung Carcinoma
        • Impression (Imaging stage): T: T3 (T_value) N: N0(N_value) M: M1c (M_value) STAGE: IVB (Stage_value)
    • 2022-02-07 Sigmoidoscopy
      • Diagnosis
        • Post OP scar, rectum
        • Mixed hemorrhoid
      • Suggestion
        • OPD f/u
      • Complication
        • No immediate complication
    • 2021-01-04 CT - abdomen
      • S/P rectal operation.
      • Right renal angiomyolipoma (3.0cm).
      • Left adrenal nodule (7mm).
      • A nodule (23mm) at RML.
    • 2019-11-04 CT - abdomen
      • S/P rectal operation.
      • Right renal angiomyolipoma (3.0cm).
      • Left adrenal nodule (7mm).
      • A small nodule (3mm) at RLL.
    • 2019-10-28 Sigmoidfiberscopy
      • Normal mucosal appearance without focal lesion from rectum to near splenic flexure colon (60cm AAV).
      • Previous surgical scar at middle rectum was seen and is fine.
    • 2019-07-05 Surgical pathology level V
      • Rectum, transanal minimally invasive surgery with local excision — Neuroendocrine tumor, G1 (carcinoid)
      • Pathologic Stage: pT1bNx(cMx); Stage I if N0 and cM0
      • The sections show following features:
        • Histologic type and grade: Neuroendocrine tumor, G1 (carcinoid)
        • Mitotic rate: <2 mitosis/10 high power fields
        • Ki-67 labeling index: <3%
        • Tumor extension: Tumor invades the submucosa
        • Margins: All margins are uninvolved by tumor
          • Distance of tumor from closest margin: 2 mm
        • Lymphvascular invasion: Not identified
        • Perineural invasion: Not identified
        • IHC: Synaptophysin(+), chromogranin A(-), Ki-67= 1%
    • 2019-06-24 CT - abdomen
      • A hepatic cyst 5 mm in S8 is suspected. Please correlate with sonography.
      • An angiomyolipoma 3.2 x 2.5 cm in right kidney lower pole.
      • Submucosal lesion 1 cm in the rectum is suspected.
    • 2019-06-24 Sigmoidfiberscopy
      • Indication: SMT at rectum was noted
      • Findings: The scope was advanced to 30cm AAV. A hard submucosal tumor, 1.5cm in size is locted at low rectum (8cm AAV, right lateral site).
      • Diagnosis: A hard submucosal tumor, 1.5cm in size is locted at low rectum (8cm AAV, right lateral site).
      • Suggestion: TAMIS local excision
    • 2019-06-03 Miniprobe Endoscopic Ultrasound
      • Pre-EUS diagnosis
        • Rectal SMT   - Endoscopic Findings
        • A hemispherical lesion with intact mucosa at middle rectal, at the level of 10 cm AAV.   - EUS Findings EUS using miniprobe 2R showed a slightly hyperechoic tumor arising from deep mucosa or submucosa, sized 11.2 mm. The consistency of the tumor was elastic firm, and there was no pillow sign.   - Diagnosis
        • Rectal submucosal tumor, nature indeterminate   - Comment
        • Recommend ESD or transanal surgery for en-blac resection of the tumor.
    • 2019-05-04 Bone densitometry - Hip
      • Left hip, BMD is 0.574 gms/cm2, about 2.1 SD below the peak bone mass (72%) and 1.6 SD below the mean of age-matched people (76%).
      • IMP: Osteopenia
    • 2019-05-03 SONO - abdomen
      • diagnosis
        • Fatty liver, mild
        • Liver cyst, S6.
      • suggestion
        • encourage exercise and diet control
    • 2019-05-03 Flow-volume curve
      • Mild restrictive ventilatory impairment
    • 2019-05-03 Colon fiberoscopy
      • Findings
        • A 1 cm SMT was noted at 10 cm.
        • The scope was inserted to cecum smoothly. Some liquid stool was noted in the colon.
      • Diagnosis
        • Internal hemorrhoid, mild
        • Submucosal tumor, rectum
    • 2018-04-18 Gynecologic ultrasonography
      • S/P lapacoscopy
      • Bilateral ovarian cyst, Suspected endometrioma
      • Uterine myoma
      • Mild Adenomyosis
    • 2018-01-10 Gynecologic ultrasonography
      • Mild Adenomyosis
      • Bilateral ovarian cyst (endometrioma)
    • 2017-10-18 Gynecologic ultrasonography
      • Mild Adenomyosis
      • Lov cyst
  • consultation
    • 2022-08-31 Chinese Medicine
      • Q
        • This 49-year-old woman who with past history of
            1. significant of rectal cancer status post transanal microscopic surgery on 2019/07/04
            1. Right middle lobe Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1,
            • EGFR mutation: L858R (-), exon 19 (+), ALK(), PD-L1: <1% diagnosed on 2022-03-22, with Giotrif since 20220325. The lung cancer treatment regimen as below:
              • 1st chemotherapy with TKIs with Giotrif since 2022-03-25.
              • Angiogenesis inhibitor C1 Cyramza since 2022-03-22.
        • Tracing back the past history, she was referred to chest surgery department because of a pathcy density (4.5cm) noted at RML under abdominal CT on 2022/02/07. According to herself, she received regular outpatient clinic follow up in colorectal department after ectal surgery, and on this February, he was found to have a pathy dendity under abdominal CT. Therefore, she was referred to chest surgery department for further evaluation. On admission, she made no specific complaint. No obvious illnes was told. Physical examination showed no obvious heart murmur. Breath sounds were clear. Chest movements were symmetric. Abdomen was soft, No tenderness nor rebounding pain was observed. Under the impression of solitary lung nodule, she was admitted for further survey.  
        • Mutation report reveal Exon 19 deteced, TKI with Afatinib 30mg 1# QDAC was prescribed. Arrange Angiogenesis inhibitor C1 Ramu 500mg on 2022-03-22, C2 Cyaramza 500mg (charge) on 2022-04-20. There were no fever or chills, no short of breath, no chest pain. Under diagnosis of Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, she was admitted for on schdule for chemotherapy .     
        • For cancer fatigue, we sincerly your help.
      • A
        • Treatment
          • 1st chemotherapy with TKIs with Giotrif since 20220325.
          • Angiogenesis inhibitor C1 Cyramza since 2022-03-22.
            • C2 Cyaramza 500mg (charge) on 2022-04-20.
            • C3 Cyaramza 500mg (charge) on 2022-07-02.
            • C4 Cyaramza 500mg chemotherapy on 2022-08-03.
        • Past history
          • Rectal cancer status post transanal microscopic surgery on 2019/07/04
          • Right middle lobe Lung cancer, adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1, EGFR mutation: L858R (-), exon 19 (+), ALK(), PD-L1: <1% diagnosed on 2022-03-22, with TKIs with Giotrif since 20220325.
    • 2022-07-07 Metabolism and Endocrinology
      • Q
        • for Cortisol; 0.53 ug/dL 
          • Free-T4 0.83 ng/dL            
          • TSH 0.249 uIU/mL          
          • ACTH <5.0 pg/mL  
        • History: Hyperthyroidism, Goiter, rectal carcinoid (NET) s/p TAMIS local excision
      • A
        • This 49-year-old female was a case of right middle lobe lung adenocarcinoma, T4N1M1c with brain, bone metastasis, ECOG 1, was admitted for following up and chemotherapy. We were consulted for low cortisol level and abnormal TFT.
        • O:
          • BW: 56.1 kg
          • HR: 65-100
          • Possible related medication: dexamethasone, clobestasol
          • AST/ALT: 13/16
          • BUN/Cr: 11/0.64
          • Na: 143, K: 4.0
          • TSH/FT4: 0.249/0.83
          • T3: unavailable
          • ACTH/Cortisol: < 5.0/0.53
          • ECG: normal sinus rhythm (2022/03)
        • A:
          • Physiological response of steroid use.
          • Abnormal TFT, DDx: sick euthyroid syndrome, secondary hypothyroidism
        • Suggestions:
          • No need of any supplement of steroid or thyroxine
          • Check T3 and complete pituitary function (IGF-1, FSH/LH, E2, prolactin) in the next lab.
          • Contact us if needed. I’d like to follow up this patient.
    • 2022-07-07 Dermatology
      • Q
        • for paronychia.
      • A
        • This patient suffered erytehamtous patches on bil palme-soles for days.
        • Imp: Hand foot sym
        • Suggestion:
          • Sinpharderm * 1 tubes/bid
          • Topsym cream * 4 tubes/bid
    • 2022-03-09 Thoracic Medicine
      • Q
        • For chemotherapy and target therapy
        • This 49-year-old patient with underlying stage 4 lung cancer has brain metastasis. She had received video assisted thoracoscopic right middle lobe lobectomy on 2022/03/07. We need your help to evaluate if she could receive chemotherapy. Thank you!
      • Impression:
        • Lung cancer, adenocarcinoma, T4N1M1c, stage IVB, with bone, brain metastasis
      • Suggestion:
        • EGFR mutation test
        • Bone RT if severe bone pain
        • We will take over this case after chest tube removed
    • 2022-03-08 Radiation Oncology
      • Q
        • For radiotherapy
      • A
        • S: For radiotherapy due to lung adenocarcinoma with brain metastasis.
          • PI: The patient is a case of adenocarcinoma of the lung, RML, with brain metastasis, s/p 3D VATS, RML lobectomy + RUL wedge + RLND on 2022-03-07. Referred for radiotherapy due to brain metastases.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Other disease: carcinoid tumor of rectum (?)
          • Previous RT Hx: (-)
        • O: ECOG: 1
          • PE: neck and bil SCF: neg; chest: status on chest tube drainage.
          • CT scan of abdomen (2022-2-7): A pathcy density (4.5cm) at RML. Some nodules at bil. lungs. Lung cancer should be ruled out. S/P rectal operation. Right renal angiomyolipoma (3.0cm). Left adrenal nodule (7mm).
          • CXR (2022-03-01): A well defined mass (36 mm) over Rt central midlung zone, RML, favor a malignant tumor. Nodular opacitiy projecting over tLt lower lung zone due to nipple shadow. Normal shape and size of heart. Costophrenic angles are preserved
          • Bone scan (2022-03-03): Prominently increased activity in the lower T-spine. The nature is to be determined. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
          • MRI of brain (2022-03-04): Brain metastases, right frontal periventricular white matter and right frontal cortex.
          • Pathology (S2022-03327, 2022-3-4): Lung, RML, CT-guide biopsy—adenocarcinoma, poorly differentiated
          • Operation (2022-03-07): 3D VATS, RML lobectomy + RUL wedge + RLND. Finding:
            • One tumor lesion was noted over RML, size about 2.0cm in diameter which invade across the horizontal fissure to RUL s/p RML lobectomy + RUL wedge.
            • visceral and parietal pleura tumor seeding
            • abolished bronchioarterial plane which has been devided together.
            • stiff, enlarge and not well-capsuled subcarina and paratrachea lymph node suspected metastasis.
            • one 24 Fr. straight chest tubes were inserted via right 8th ICS.
        • A: Adenocarcinoma of the lung, RML, with brain metastasis, s/p 3D VATS, RML lobectomy + RUL wedge + RLND.
        • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis
          • Goal: palliation
          • Treatment target and volume: metastatic brain tumors
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 3000cGy/10 fractions of the metastatic brain tumors
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her brother. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 1500, 2022-3-11.
  • chemoimmunotherapy
    • 2022-08-18 ~ undergoing - Giotrif (afatinib) 30mg/tab 1# QOD
    • 2022-09-26 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-08-29 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-08-02 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-07-08 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-04-20 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-03-22 - Cyramza (ramucirumab) 500mg 1.5hr

700504868

221004

  • lab data

    • 2022-06-30 EGFR specimen number S2022-09386
    • 2022-06-30 EGFR G719X not detected
    • 2022-06-30 EGFR Exon19 del not detected
    • 2022-06-30 EGFR S768I not detected
    • 2022-06-30 EGFR T790M detected
    • 2022-06-30 EGFR Exon20 ins not detected
    • 2022-06-30 EGFR L858R detected
    • 2022-06-30 EGFR L861Q not detected
    • 2022-05-30 ASMA Positive ; 1:80
    • 2022-05-30 AMA Positive ; 1:20
    • 2022-05-26 Factor IX assay 78.2 %
    • 2022-05-26 Factor VIII assay 103.4 %
    • 2022-05-26 Cryoglobulin Negative
    • 2022-05-23 ANA Speckled 1:80
    • 2022-05-23 Von willebrand factor 224.8 %
    • 2022-05-21 PR3 Negative IU/ml
    • 2022-05-21 PR3 Value <0.2 IU/ml
    • 2022-05-21 MPO Negative
    • 2022-05-21 MPO Value <0.2 IU/ml
    • 2022-05-21 Anti-ENA SS-A(Ro) 89 EliA U/ml
    • 2022-05-21 Anti-ENA SS-B(La) 0.3 EliA U/ml
    • 2022-05-21 Anti-ds DNA Antibody 0.8 IU/ml
    • 2022-05-21 Anti-Cardiolopin IgG 1.9 GPL-U/mL
    • 2022-05-21 Anti-cardiolipin-IgM 62 MPL U/mL
    • 2022-05-21 Anti-ENA Sm 2.2 EliA U/ml
    • 2022-05-21 Anti-ENA RNP 0.6 EliA U/ml
    • 2022-05-19 RF 364.8 IU/mL
    • 2022-05-19 C3 118.3 mg/dL
    • 2022-05-19 C4 <8 mg/dL
    • 2022-05-19 IgG (blood) 1143 mg/dL
    • 2020-08-05 PD-L1(22C3) specimen number S2020-09426
    • 2020-08-05 PD-L1(22C3) TPS >= 1% and <50%
    • 2020-07-30 ROS1 specimen number S2020-09426
    • 2020-07-30 ROS1 not detected
    • 2020-07-27 ALK IHC specimen number S2020-09426
    • 2020-07-27 ALK IHC Negative
    • 2020-07-24 EGFR specimen number S2020-09426
    • 2020-07-24 EGFR G719X Not detected
    • 2020-07-24 EGFR Exon19 del Not detected
    • 2020-07-24 EGFR S768I Not detected
    • 2020-07-24 EGFR T790M Not detected
    • 2020-07-24 EGFR Exon20 ins Not detected
    • 2020-07-24 EGFR L858R detected
    • 2020-07-24 EGFR L861Q Not detected
    • 2020-07-09 Anti-HCV NONREACTIVE
    • 2020-07-09 Anti-HCV Value 0.06 S/CO
    • 2020-07-09 HBsAg NONREACTIVE
    • 2020-07-09 HBsAg (Value) 0.13 S/C value
    • 2020-07-09 Anti-HBs 14.17 mIU/mL
  • exam finding

    • 2022-10-03 KUB
      • Compression fracture of T11-L2.
      • Stool retention in the bowel.
    • 2022-09-25 CXR
      • Lt pleural thickening?
      • increased opacity over Lt lower hemithorax with obliteration of hemidiaphgram and Lt shift of heart
      • a poorly defined nodular opacity at RUL, and subtle LUL nodule, stationary
      • Osteoblastic metastasis in many vertebrae
      • Mild dextroscoliosis of the T-spine
      • mild cardiomegaly
    • 2022-09-26 SONO - chest
      • No pleural effusion.
      • Left lower lung consolidation.
    • 2022-09-16 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/05/16, all the previous bone lesions are more eivdent and some new bone lesions are noted, suggesting multiple bone metastases in progression.
    • 2022-09-15 MRI - T-spine
      • Known a case of lung cancer. Abnormal enhancing lobulated mass lesion (>4.2cm) over left lateral mass of T2-T3-T4 and spinous process, causing severe spinal stenosis and compression of thoracic cord. Abnormal marrow enhancement of T2-T3 vertebral bodies. Compatible with metastases.
      • Also abnormal enhancing lesions over T9 & T12 spinous process.
      • Also abnormal marrow enhancement of T12 and L1 vertebral bodies. Favor metastatic lesions.
    • 2022-09-14 Eelectroencephalogram, EEG
      • This EEG study recorded background alpha rhythm (8-9 Hz) and plenty beta activity with occasional transient diffuse slow waves.
      • No epileptiform discharge. Please correlate with clinical features
    • 2022-09-14 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
      • Finding
        • MNCV: difficult access to right hand due to IV site. delayed CMAPs onset latency of bilateral peroneal nerves; slow motor conduction velocity of left median, bilateral ulnar nerves across elbow, bilateral peroneal and left tibial nerves
        • SNCV: slow sensory conduction velocity of bilateral ulnar and right median nerves
        • F-wave: delayed responses of bilateral peroneal and tibial nerves
        • H-reflex: delayed responses of bilateral lower limbs
        • Thermal quantitative sensory test showed abnormal warm and cold threshold in left lower limb
      • Conclusion
        • This NCV study suggested bilateral lumbosacral radiculopathy, bilateral ulnar neuropathy across elbow and bilateral median distal neuropathy.
        • Thermal quantitative sensory test suggested small fiber neuropathy.
        • Please correlate with clinical features.
    • 2022-09-13 Humerus Lt
      • avalsion fracture of proximal humerus, involving greater tuberosity, with suspect combined radiolucency
    • 2022-09-07 CXR
      • Lt pleural thickening with minimal pleural effusion
      • large LLL retrocardiac tumor opacity and a poorly defined nodular opacity at RUL, and subtle LUL nodule, stationary
      • Osteoblastic metastasis in many vertebrae
      • Mild dextroscoliosis of the T-spine
      • mild cardiomegaly
    • 2022-08-12 CT - lung/mediastinum/pleura
      • Findings
        • Soft tissue mass at left lower lobe up to 7.5cm with attachment with parietal and visceral pleura is found. In comparison with CT dated on 2022-04-26, the lesion is stationary.
        • Several irregular shaped patch/mass at right upper lobe and other lobes. Stable.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Mild left pleural effusion is found.
        • Calcified coronary arteries is found.
        • Small lymph nodes are found at both sides of the mediastinum.
      • Imp
        • LEFT LOWER LOBE lung cancer with lung to lung meta. Mediastinal lymphadenopathy and bone meta. These lesions are stationary.
    • 2022-08-05 MRI - brain
      • Indication: Lung cancer, LLL, adenocarcinoma, cT4N2M1c, with brain metastasis, with TKI Giotrif since 2020/07/16, Cyramza C1 since 2020/08/05 with disease progression and brain metastasis (n=3); ECOG =1. s/p Brain RT on 2022/6/01.
      • Findings
        • multiple enhancing nodules at the left frontal cortex, left occipital cortex, and right anterior insula, compatible with brain metastases. Most of the tumors are stationary or smaller. But the one at left anterior frontal lobe is enlarged (1.3m) with increased extent of vasogenic edema.
        • mild brain atrophy with prominent sulci, fissures and dilated ventricles.
        • multiple nonspecific hyperintense patches in T2WI at bilateral periventricular white matter, leukoaraiosis is considered.
        • no midline shift nor brain herniation.
        • no abnormal bright up on DWI.
        • unremarkable skull base and calvarial vault.
      • Impression:
        • Multiple brain metastases, the one at left anterior frontal lobe is enlarged (1.3cm).
        • Brain atrophy and leukoaraiosis.
    • 2022-06-09 Patho - bronchus biopsy
      • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
      • Sections show neoplastic acinar glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • 2022-06-08 Whole body PET scan
      • Glucose hypermetabolic lesions in the left lower lung as well as left pleural effusion, compatible with the primary lung cancer with malignant pleural effusion.
      • Glucose hypermetabolic lesions in several lung lobes, highly suspected lung cancer with lung to lung metastases.
      • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal lymph nodes, highly suspected lung cancer with regional lymph nodes metastases.
      • Glucose hypermetabolic lesions in the left adrenal region and multiple skeleton as above-mentioned, highly suspected lung cancer with distant metastases.
      • Increased FDG uptake in the right lobe of the thyroid gland, probably lung cancer with thyroid metastasis or another primary cancer of thyroid, suggesting further investigation.
      • Left lower lung cancer with left pleura, bilateral lung lobes, bilateral regional lymph nodes, left adrenal and multiple bone mets, cT4N3M1c, stage IVB (AJCC, 8th ed.), by this F-18 FDG PET scan.
    • 2022-05-16 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2021/12/24, two lesions in the left 11th costovertebral junction and in a upper T-spine are new, and the nature is to be determined, suggesting follow-up with bone scan in 3-6 months for investigation.
      • Other lesions in the posterior aspect of the left 8th and 9th ribs, respectively, T12 spine, L3 spine, right femoral trochanter, bilateral shoulders, and S-I joints show slightly less evident.
    • 2022-05-14 MRI - brain
      • Enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part, artifact? stationary.
    • 2022-04-26 CT - chest
      • LLL cancer T4N3M1b, increase in size of priamry tumor and stationary of lung to lung metastatic lesion, left pleura and spine metastases, but newly developed left ribs metastasis as compared with previous CT study on 2021/12/23.
    • 2021-12-24 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2020/12/23, the lesions in the posterior aspect of the left 8th and 9th ribs, some middle and lower T-spines and L3 spine are a little more prominent. Bone metastases in a little more progression should be watched out. Please correlate with other clinical findings for further evaluation.
      • No prominent change is noted in other bone lesions.
    • 2021-12-23 CT - chest
      • left lower lobe lung cancer with lung to lung meta and lumbar spine meta. stationary.
    • 2021-12-22 MRI - brain
      • Regressed Small bi-frontal cortical nodules, a residual nodule in left or artifact?
    • 2021-08-26 CT - chest
      • Left lower lobe mass with enlargement. Either tumor progression or mucus impaction is suspected. Suggest contrast enhanced study.
      • Right upper lobe and right lower lobe and left lower lobe nodules. Stationary. cT4N3M1b.
    • 2021-03-11 CT - chest
      • right upper lobe and left lower lobe lung cancer with lung to lung and bone meta. Stable. cT4N3M1b.
    • 2020-12-23 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2020/07/15, one faint hot spot in the posterior aspect of the left 8th rib comes to less evident, but the other faint hot spot in the post. aspect of the left 9th rib becomes more prominent, suggesting bone mets with mixed response to current therapy.
      • Increased activity in the T12 spine shows more evident compared with the previous study on 2020/07/15, the nature still is to be determined (bone mets, DJD, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in L3 spine, bilateral shoulders and S-I joints.
    • 2020-12-24 CT - chest
      • Left lower lobe lung cancer with lung to lung meta and bone meta. T4N3M1b, in regression.
    • 2020-09-29 CT - chest
      • LLL cancer T4N3M1b, significant in regression of lung tumors and
      • metastatic mediastinal and hilar LAP, but stationary of left pleural and spine metastases as compared with previous CT study on 2020/07/13.
    • 2020-07-15 Tc-99m MDP whole body bone scan
      • A hot spot in the posterior aspect of the left 8th rib and a faint hot spot in the post. aspect of the left 9th rib, malignancy with bone mets may be considered.
      • Increased activity in the T12 spine and L3 spine, the nature is to be determined (bone mets, DJD, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in bilateral shoulders and S-I joints.
    • 2020-07-14 MRI - brain
      • Small bifrontal cortical nodules, favor metastases.
    • 2020-07-13 Patho - lung transbronchial biopsy
      • Lung, ? side, needle biopsy—adenocarcinoma, moderately differentiated
      • Sections show solid nests and glandular tumor cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
    • 2020-07-13 CT - chest
      • Findings
        • Lungs and large airways:
          • an irregular, large, soft-tissue tumor (at least 70 mm in largest dimension) in LLL, involving the hilum, inferior pulmonary artery and vein, and adjacent mediastinum and pericardium.
          • multiple nodular lesions of varying sizes in bilateral lungs up to 36 mm at RUL due to lung to lung metastasis.
        • Mediastinum and hila: metastatic LAPs in stations 5, 7, and left 10.
        • Vessels: mild coronary arterial calcification
          • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
          • Central pulmonary arteries: normal caliber.
      • Impression:
        • LLL cancer T4N3M1b, stage IVA.
    • 2020-07-09 SONO - chest
      • Left side moderate amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis.
      • Pleural biopsy was not done due to INR:2.51.
    • 2020-07-01 CXR
      • Several nodular opacity projecting in the both upper lung are suspected. Please correlate with CT.
      • Massive left side Pleura effusion is suspected.
      • Spondylosis with scoliosis of the T-spine with convex to right side
  • consultation

    • 2022-09-28 Rehabilitation
      • Q
        • for bedside rehabilitation
        • This 76-year-old woman was a case with past hsitory of Rheumatoid arthritis and hypertension and a case of Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosedand on 2020-08; T4: LLL mass with bilateral lung to lung; N2: right mediastinal LAPs; M1C: brain, bone, lung to lung metasatsis; EGFR mutation: L858R (+), exon19(-), ALK(-).
        • Tracing back the past history, she suffered from cough productive of whitish sputum for many months, chest tightness and exertional dyspnea for 2-3 months. She visited our chest OPD for help, chest x-ray films and showed Several nodular opacity projecting in the both upper lung are suspected. massive left side Pleura effusion is suspected, than was arranged admission on 2020-07-17.
        • After admissin, arranged sonography of chest, left side moderate amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis. The 2nd chest echo on 20200710 displayed L’t pleural effusion, lung mass s/p pigtail insertion. Arranged CT guiding biopsy on 20200713 and pathology disclosed non-small cell lung cancer initially, then adenocarcioma was confirmed after speciall stain. Brain MRI was done and disclosed small bifrontal cortical nodules, favor metastases. Whole body bone scan also done 20200715 and disclosed multiple bone metastases in the left rib and spine. The lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasislung cancer stage was T4N3M1b, stage IV was diagnosed.
        • We well explained the treatment to the lung cancer and after disscussion with her familes member, TKI with Giotrif was prescried since 2020-07-16. EGFR: T790M detected and L858R detected. change TKI to Tagrisso (2022-07-13 ~ ).
        • This time, she suffered from Severe Chest and back pain for one week, other symptoms included cough, hemoptysis, dyspnea on exertion, nausea, poor appetite and body weight loss. Under the impression of Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, she was admitted for pain control and radiotherapy.
      • A
        • I have called NP for more clinical information. The patient suffered from lower limbs weakness and numbness due to suspected T-spine mets after admission.
          • T spine MRI findings:
            • Known a case of lung cancer. Abnormal enhancing lobulated mass lesion (>4.2cm) over left lateral mass of T2-T3-T4 and spinous process, causing severe spinal stenosis and compression of thoracic cord. Abnormal marrow enhancement of T2-T3 vertebral bodies. Compatible with metastases.
            • Also abnormal enhancing lesions over T9 & T12 spinous process.
            • Also abnormal marrow enhancement of T12 and L1 vertebral bodies. Favor metastatic lesions.
          • He could walk on admission, but was bed-ridden or wheelchair bounded now.
            • MP over lower limbs
            • Before 20220911: 5/5
            • On 20220912: 2/2
            • After 20220913: 0/0
          • Due to lower limbs weakness and numbness, we were consulted for further rehabilitation training.
        • PE
          • 2022/09/28 12:40 T/P/R: 38.0C / 95bpm / 20bpm BP:120/59mmHg
          • height: 163.5 Body weight: 57.6 BMI:21.5
          • Consciousness: clear
          • Cognition: intact, oriented to time, person and place, could follow orders
          • Speech: no aphasia, no obvious dysarthria
          • Swallowing: take general diet without choking
          • Sphincter: Foley+, stool incontinent; preserve anal sensation and contraction
          • MP: R L
          •   (C5) Deltoid/Biceps            5         4
          •   (C6) Wrist extensor            5         4
          •   (C7) Triceps                   5         4
          •   (C8) Flex. dig. profundus      5         5
          •   (T1) Hand intrinsics           5         5 
          •   (L2) Iliopsoas                 0         0
          •   (L3) Quadriceps                0         0
          •   (L4) Tibialis ant.             0         0
          •   (L5) Ext. hallu. longus        0         0
          •   (S1) Gastrocnemus              0         0
        • AP and LAT. views of left humerus show: avalsion fracture of proximal humerus, involving greater tuberosity, with suspect cpmbined radiolucency
          • -> left arm sling protection
        • Sensory: bilateral lower limbs numbness below T10
        • Functional status: could sit-up under maxA
        • BADL: eating and grooming minA; toileting, bathing, and dressing needs maxA
        • DTR: decrease in bilateral lower limbs
        • Barbinski: positive/negative
        • MRS: 5 (need followed up)
      • Assessment
        • Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, ECOG 1
        • Malignant pleural effusion
        • hypertension
        • Chronic obstructive pulmonary disease
        • Encounter for antineoplastic immunotherapy
        • T-spine mets, T2-4, T9, T12-L1
        • SCI, ASIA B, level T9
      • Plan
        • Rehabilitation programs: Bedside PT, OT rehabilitation programs
        • Goal: improve ADL, muscle power and endurance
    • 2022-09-28 Infectious Disease
      • A
        • The patinet is case of adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis.
        • S/C: oxacillin-resistatant Stapylococcus capitis
        • Agree with your use of zyvox. Please adjust antibiotic according to culture results and clinical conditions.
    • 2022-09-16 Radiation Oncology
      • Q
        • for L spine lesions, arrange radiotherapy
      • A
        • This patient has suffered from lower limb weakness, constipation and urine difficulty since last Saturday. Falling accidence with avalsion fracture of proximal humerus, involving greater tuberosity happened on last Saturday, too.
        • MRI of spine on 20220915 showed abnormal enhancing lobulated mass lesion (>4.2cm) over left lateral mass of T2-T3-T4 and spinous process, causing severe spinal stenosis and compression of thoracic cord. Abnormal marrow enhancement of T2-T3 vertebral bodies, which is compatible with metastases. Also abnormal enhancing lesions over T9 & T12 spinous process & abnormal marrow enhancement of T12 and L1 vertebral bodies are norted; metastatic lesions are all favored.
        • Palliative RT to T2-4 spines had been prescribed on 20220908 to 20220909, for 600cGy/2 fractions, and was interrupted after avalsion fracture of proximal humerus was noted. I have started RT to T2-4 spines at 3 pm today, and treatment will be continued next week. Please keep dexamethsone use during spine RT and increase dose if necessary. The recovery of muscle power may not be complete because the dueration of spinal cord compression.
    • 2022-09-13 Neurology
      • Q
        • for numbness of lower limbs for 2-3 days
      • A
        • According to the patient’s statement, she was able to walk last week when admission. However she suffered from progressive lower limbs weakness and numbnesss since admission. Left lower limb was worse than the right. In addition, she complained of abnormal sensation below nipple and urinary difficulty. Middle back and chest diffuse pain was also noted since last week. Hands numbness was also noted.
          • NE E4V5M6
          • CNs: intact
          • MP upper >4/>4, lower 3/2-3
          • DTR 2+/2+
          • sensation: below nipple parethesia with distal prominence, normal proprioception
          • FNF: no dsymetria
        • brain MRI in 2022/08: Multiple brain metastases, the one at left anterior frontal lobe is enlarged (1.3cm).
          • impression: bilateral lower limbs numbness and weakness with urinary retention. suspect myelopathy below T4, suspected new organic brain lesion
        • suggestion:
          • Do T-spine MRI with/without contrast enhancement (including whole spine saggital view) if feasible
          • consider to repeat brain MRI if negative spine MRI findings
          • do NCV (upper /lower limb motor and sensory nerve conduction study, F-wave, H-reflex) and QST to survey possible polyneuropathy
          • EEG should be considered if seizure or nonconvulsive seizure was suspected
    • 2022-09-12 Orthopedics
      • Q
        • Painful limitation of left shoulder was noted due to slipping (fall down) at the toilet tonight. Left humoral head fracture was noted on X-ray. So, we would like to request your expertise for further management. Thank you.
      • A
        • Left shoulder pain after falling down tonight
        • X-ray : Left proximal humerus GT avulsion fracture
          • Adequate pain control
          • Arm sling protection
          • Check left shoulder X-ray after R/T tomorrow
          • Explain the current condition and further management to the patient and family
    • 2022-05-16 Radiation Oncology
      • Q
        • Consult for brain radiotherapy
        • This 76-year-old woman was a case with past history of Rheumatoid arthritis and hypertension, she was not regular control. A case of Lung cancer, adenocarcinoma, T4N2M1C, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosedand on 2020-08; T4: LLL mass with bilateral lung to lung; N2: right mediastinal LAPs; M1C: brain, bone, lung to lung metasatsis. EGFR mutation: L858R (+), exon 19 (-), ALK (-).
        • The lung cancer treatment regimen as below:
          • 1st chemotherapy with TKI Giotrif since 2020-07-16, added Cyramza C1 since 2020-08-05.
        • This time, she admission for chemotheapy with C15-6 Cyramza (2 vial free).
        • After admission, for lung cancer survey, brain MRI was complete that show enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part.
      • A
        • Subjective:
          • History: This 76-year-old woman was a case of lung cancer, adenocarcinoma, cT4N2M1c, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosed on 2020-08; EGFR mutation: L858R (+), exon 19 (-), ALK(-), under 1st target therapy with TKI Giotrif since 2020-07-16, added Cyramza C1 since 2020-08-05. This time, she was admitted for chemotherapy with C15-6 Cyramza (2 vial free). After admission, brain MRI showed enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part.
            • Previous RT: s/p RT to pelvis and vaginal stump in 2016.
            • Other disease: Rheumatoid arthritis and hypertension.
            • Family history: denied.
          • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
          • Widow. Caregiver: her sons (n=3). Job: housewife. Mild or no economic stress.。
          • Language: Mandarin. Taiwanese.
          • Religion: buddism.
        • Objective:
          • General Condition-ECOG: 1.
          • PE, 2022/05/16: No SCF LNs.
          • Pathology, 2020/07/13: Lung, needle biopsy—adenocarcinoma, moderated differentiated.
          • Images:
            • Chest CT on 2022/04/26: LLL cancer T4N3M1b, increase in size of primary tumor and stationary of lung to lung metastatic lesion, left pleura and spine metastases, but newly developed left ribs metastasis as compared with previous CT study on 2021/12/23.
            • Brain MRI, 2022/05/14: Enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another residual nodule in left or artifact, stationary. After IV contrast administration shows well or heterogenous enhancement of those nodules or tumors. Imp: Enlarged bi-frontal cortical/subcortical nodules with increased perifocal edema at right, another small residual nodule in left anterior part.
        • Diagnosis: Lung cancer, LLL, adenocarcinoma, cT4N2M1c, stage IVB with brain, bone, lung to lung metastasis, ECOG 1, diagnosed on 2020/08; EGFR mutation: L858R (+), exon 19 (-), ALK(-), under 1st target therapy with TKI Giotrif since 2020/07/16, Cyramza C1 since 2020/08/05 with disease progression and brain metastasis (n=3); ECOG =1.
        • Suggest:
          • Radiotherapy.
          • Goal: Palliative.
          • RT Plan may be designed as the following one:
            • Target & Volume: Metastatic brain tumors (n=3).
            • Technique: VMAT & IGRT (OBI).
            • Dose & Fractionation: 3960cGy/12 fractions.
        • Plan:
          • Palliative R/T is suggested for tumor control. Possible toxicity (malaise, IICP & hair loss) is told. CT simulation is arranged on May 16 15:30pm. Treatment will be started on Wednesday if feasible.
    • 2021-10-28 Dermatology
      • Q
        • For Pyogenic granuloma on R’t toenail for wks, severe painful
        • After admission, under the ANC: 4541 /uL. Chemotherapy C10 Cyramza total 200mg were done smoothly respectly on 20211027 and kept TKI with giotrif 30 mg/tab 1 tab PO QDAC continued given for lung cancer control. There were no nausea, vomiting, SOB or chest pain after chemotherapy. Only mild general malaise was mentioned and improved after bed reset and medica treatment.
      • A
        • This patient suffered from multiple granulation on bil fingeres and toenails for days
        • Imp: Pyogenic granuloma
        • Suggestion:
          • Arrange liq N2 Tx
  • chemoimmunotherapy

  • Tagrisso - osimertinib 80mg/tab 1# QD PO

    • 2022-07-13 ~ undergoing
  • Cyramza - ramucirumab (NSCLC recommended dose in package insert: in combination with erlotinib, 10mg/kg Q2W IVD 60min)

    • 2022-09-20 - ramucirumab 200mg 15hr
    • 2022-05-13 - ramucirumab 200mg 15hr
    • 2022-03-15 - ramucirumab 200mg 15hr
    • 2022-02-17 - ramucirumab 200mg 15hr
    • 2021-12-21 - ramucirumab 200mg 15hr
    • 2021-11-23 - ramucirumab 200mg 15hr
    • 2021-10-27 - ramucirumab 200mg 15hr
    • 2021-04-13 - ramucirumab 200mg 15hr
    • 2021-03-02 - ramucirumab 200mg 15hr
    • 2021-01-19 - ramucirumab 200mg 15hr
    • 2020-12-22 - ramucirumab 200mg 15hr
    • 2020-11-25 - ramucirumab 200mg 15hr
    • 2020-10-27 - ramucirumab 200mg 15hr
    • 2020-09-28 - ramucirumab 200mg 15hr
    • 2020-09-03 - ramucirumab 200mg 15hr
    • 2020-08-05 - ramucirumab 200mg 15hr
  • Giotrif - afatinib 30mg/tab 1# QDAC PO

    • 2020-07-16 ~ 2022-07-13

[assessment]

  • There has been an active problem with hemoptysis since 2022-09-07. Ramucirumab is associated with an increased risk of hemorrhage and GI hemorrhage. Various exclusion criteria in some non-small cell lung cancer trials included a recent history of gross hemoptysis, evidence of major airway or blood vessel involvement or intratumor cavitation; the risk of pulmonary hemorrhage in patients with such criteria is not known. Monitoring should be conducted on a continuous basis.
  • The use of ramucirumab has also been associated with hypertension (incidence 16% to 25%). This patient’s blood pressure level never exceeded 125mmHg during the last seven days of hospitalization. Hypertension appears to be less of a problem.
  • Lab results
    • 2020-07-24 EGFR L858R detected => afatinib - 2020-07-16 ~ 2022-07-13
    • 2022-06-30 EGFR T790M detected => osimertinib - 2022-07-13 ~ undergoing
  • It has been reported that sequential afatinib and osimertinib demonstrated encouraging activity in patients with EGFR mutation-positive NSCLC and acquired T790M. Activity was observed across all subgroups, including patients with poor ECOG PS or brain metastases. ECOG PS and incidence of brain metastases remained stable prior to, and after, afatinib treatment. (ref: Sequential afatinib and osimertinib in patients with EGFR mutation-positive NSCLC and acquired T790M: A global non-interventional study (UpSwinG). Lung Cancer. 2021;162:9-15. doi:10.1016/j.lungcan.2021.09.009)

700040696

221003

  • exam finding
    • 2022-08-26 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver cyst, small, S8
        • Parenchymal renal disease and renal cyst, bilateral, c/w ESRD
        • pancreas and spleen masked by gas.
      • Suggestion
        • Semi-annual ultrasound follow up.
    • 2022-08-03 CT - abdomen
      • History
        • 20220331 gastroscopy: One huge lumen-protruding ulcerative tumor with mucosa friability at LC side of antrum involving the angularis. The pylorus seems to be spared. IMP: Highly suspected gastric cancer, Borrmann type III, antrum LC, angularis involved.
        • 20220401 CT:gastric cancer, cT3N2M1?, cSTAGE:IVB
        • 20220413 s/p radical subtotal gastrectomy with en bloc distal pancreatectomy:Adenocarcinoma of gastric antrum with pancreas invasion, pT4bN1(cM0) stage IIIB
      • Indication: FU
      • Findings:
        • S/P subtotal gastrectomy
          • Prior CT identified One enlarged node measuring 1.5 x 1 cm in right lower pelvis is noted again, stationary. Follow up is indicated.
        • Prior CT identified three enhancing round-shaped lymph nodes in left inguinal area (size: < 5 mm) are noted again, stationary. Follow up is indicated.
          • In addition, there are several ovoid-shaped enlarged nodes with fatty hilum that are c/w benign reactive nodes.
        • There are several small poor enhancing lesions in both hepatic lobes and the largest one 1.4 cm in S2 that may be cysts. Please correlate with sonography.
        • Both kidney show small size, few cysts, and thin parenchyma that are c/w ESRD.
        1. There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
      • IMP:
        • S/P subtotal gastrectomy. There is no evidence of tumor recurrence.
        • Prior CT identified One enlarged node measuring 1.5 x 1 cm in right lower pelvis is noted again, stationary. Follow up is indicated.
    • 2022-07-02 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • S/p port-A placement with its tip at Superior vena cava.
      • Increased pulmonary vasculature is found.
    • 2022-05-27 CXR
      • Enlargement of cardiac silhouette.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
      • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • 2022-04-13 Patho - stomach subtotal/total (tumor)
      • Diagnosis
        • Stomach, antrum, radical subtotal gastectomy — adenocarcinoma, poorly differentiated; AJCC 8th edition: pStage IIIB, pT4bN1(if cM0) or pStage IV, pT4bN1(if cM1: by CT-finding)
        • Pancreas, body, en block distal pancreatectomy — adenocarcinoma, by direct invasion
        • Duodenum, radical subtotal gastectomy — negative for malignancy
        • Omentum, omentectomy — negative for malignancy
        • Lymph node, group 1, dissection — negative for malignancy (0/4)
        • Lymph node, group 3, dissection — negative for malignancy (0/3)
        • Lymph node, group 4, dissection — adenocarcinoma, metastatic (1/ 4)
        • Lymph node, group 5, dissection — negative for malignancy (0/1)
        • Lymph node, group 6, dissection — negative for malignancy (0/3)
        • Lymph node, group 7, 8, 9, 11p, 12, dissection — adenocarcinoma, metastatic (1/ 9)
        • Lymph node, group 14v, dissection — negative for malignancy (0/1)
      • Microscopic Description:
        • Histologic Type: Adenocarcinoma, Lauren classification of adenocarcinoma: Intermediate type (tubular)
        • Histologic Grade: G3: Poorly differentiated,
        • Tumor Extension: Tumor invades adjacent structures/organs(specify): pancreas
        • Margins
          • Proximal margin: uninvolved by invasive carcinoma: 3.4 cm
          • Distal margin: uninvolved by invasive carcinoma: 1.1 cm
          • Radial margin: uninvolved by invasive carcinoma: 0.1 cm
          • Pancreatic resection margin: 0.7 cm
        • Lymphovascular Invasion: present
        • Perineural Invasion: present
        • Regional Lymph Nodes: please see diagnosis
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply) :absent
          • Primary Tumor (pT): pT4b: Tumor invades adjacent structures/organs
          • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0 or cM1(CT-finding)
        • Additional Pathologic Findings
          • Intestinal metaplasia: present
          • Low-grade dysplasia: present
          • High-grade dysplasia: absent
          • Helicobacter pylori-type gastritis: absent
          • Autoimmune atrophic chronic gastritis: absent
          • Polyp(s): absent
        • A Schwannoma, measuring 0.2 x 0.1 cm, is seen in muscularis propria of pylorus.
        • The immunohistochemical stains reveal S-100(+), SMA(-), CD34(-), Desmin(-) and CD117(-).
    • 2022-04-12 Whole body PET scan
      • Glucose hypermetabolism in the antrum of the stomach, compatible with primary gastric malignancy.
      • Glucose hypermetabolism in the region about the lower end of the esophagus. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in a focal area in the right lower pelvis, possibly more benign in nature. However, please follow up other imaging modalities for further evaluation and to rule out the possibility of malignnacy or metastasis of low FDG uptake.
      • Increased FDG accumulation in the colon and rectum. Physiological FDG accumulation is more likely.
    • 2022-04-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (121 - 51.2) / 121 = 57.69%
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild tricuspid regurgitation, trivial aortic and mitral regurgitation
      • Impaired LV relaxation
      • Dilated LA, LV hypertrophy
    • 2022-04-07 Colonoscopy
      • Colon polyp, Paris classification 0-IIa, sigmoid colon, s/p cold polypectomy and Sureclip*2
      • Diverticulum, ascending colon
      • Internal hemorrhoid
    • 2022-03-31 CXR
      • Increase bilateral lung markings.
      • Thoracic spondylosis.
    • 2022-03-31 ECG
      • Sinus rhythm with occasional Premature ventricular complexes
      • Left ventricular hypertrophy with repolarization abnormality
    • 2022-03-31 Esophagogastroduodenoscopy, EGD
      • Reflux esophagitis LA grade A
      • Highly suspected gastric cancer, Borrmann type III, antrum LC, angularis involved, s/p biopsy*6 pieces
    • 2022-03-30 Peropheral Vascular Test - AV fistula
      • clinical diagnosis: S/P left radiocephalic AV fistula, interval duplex F/U
      • S/P left radiocephalic AV fistula, VF at inflow radial artery 655-738 ml/min, anastomotic diameter 6.0x10.8 mm, juxta-anastomotic segment 7.1 mm, proximal cephalic vein aneurysmal formation 23.2 mm without thrombus within, then cephalic vein 7.0 mm with PS 68 cm/s, A-puncture site diameter 10.8 mm (depth 2.4 mm), intervening segment 3.0 mm (relatively reduced) with mosaic flow pattern and pressure build-up PS 201.6 cm/s, Vpuncture site 8.9 mm (depth 2.2mm), cubitobasilic vein 6.0mm, upper arm basilic vein 6.2mm, continuous flow pattern over draining basiloaxillary vein indicating no overt outflow obstruction
      • Recommendation: Preemptive PTA to stenotic cubital cephalic vein to avoid further aneurysmal formation of upstream cephalic vein
      • Suggestion: PTA
    • 2021-11-03 Peropheral Vascular Test - AV fistula
    • 2021-02-24 Peropheral Vascular Test - AV fistula
    • 2020-09-30 Peropheral Vascular Test - AV fistula
    • 2018-09-03 Impedance audiometry
      • Tymp: R’t type B, L’t type A.
      • ART: Bil absent.
      • PTA
        • Reliability: fair
        • Average: R’t 69 dB HL.
        • R’t moderate to profound mixed type HL (BC 1k & 4k Hz masking dilemma).
        • L’t severe to profound mixed type HL.
    • 2017-05-11 CT - abdomen
      • Atrophy of kidneys with cysts (1.3-2.4cm). Bil. hydronephrosis and hydroureter. Distention of urinary bladder.
    • 2017-03-04 SONO - Nephrology
      • Finding:
        • Size Shape
          • R’t: 8.68 cm, uneven surface
          • L’t: 8.98 cm, uneven surface
        • Cortex
          • R’t: Echogenicity: increased; Thickness: decreased
          • L’t: Echogenicity: increased; Thickness: decreased
        • Pyramid:
          • R’t: prominent
          • L’t: prominent
        • Sinus
          • Not Dilated
        • Cyst
          • R’t: cortical, single,0.9cm in the middle kidney
          • L’t: cortical, parapelvic, multiple
          • L’t: cortical, parapelvic, multiple, 3 cystic lesions, the largest one is 2.5 cm in the middle kidney
        • Stone
          • None
        • Mass
          • None
      • Interpretation
        • Bilateral small kidneys with chronic parenchymal changes.
        • Bilateral renal cysts.
  • consultation
    • 2022-04-06 Urology
      • Q
        • For evaluation of possible bladder cancer
        • This is a 66 y/o man who was admitted to our hospital due to UGI bleeding.
        • Abdominal CT on 20220401 revealed T3N2M1?, Stage:III or IVB.
        • We suspect the involvement of the bladder due to thickening of the bladder wall and enlargement of lymph nodes near the bladder.
        • Please kindly assist to evaluate the patient and advise us on the management of the condition.
      • A
        • I have visit this patient and his family. The studies were checked.
        • After recheck the CT scan, the right pelvic nodule could be right distal ureter in my opinion.
        • Due to no hydronephrosis, smooth bladder wall and no gross hematuria, cancer from urinary tract is not likely.
        • Please check urine cytology 3 sets in different days first. Cystoscopy or ureteroscopic exams could be the next step if abnormal finding.
        • Otherwise you may treat his gastric cancer first. Uro. clinic follow up is indicated. Thanks for your consultation.
    • 2022-03-31 Nephrology
      • Q
        • This is 66 y/o man who has underlying disease of
          • ESRD under H/D W246
          • Otitis media, unspecified, left ear
          • Sensorineural hearing loss, bilateral
          • AKI with obstructive uropathy s/p temporary HD and transurethral incision of bladder neck was done at WanFang Hospital
        • The patient was admitted due to upper GI bleeding.
        • We need you to arrange him to accept hemodialysis on QW246
      • A
        • We will arrrange HD QW246. Please prescribe EPO 5000U qW4 if Hb<11.
  • surgical operation
    • 2022-04-13
      • Surgery
        • radical subtotal gastectomy with en block distal pancreatectomy
        • D2 LN dissection
      • Finding
        • distal gastric ulcerative mass with direct invasion to pancreas body
        • multiple LN was noted
  • radiotherapy
    • 2022-05-24 ~ 2022-06-?? - RT to the stomach and adjacent lymphatic drainage area: 16.2 Gy/ 9 fx.
  • chemoimmunotherapy
    • 2022-09-15 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2400mg 3250mg 46hr (adjuvant FOLFOX)
    • 2022-08-31 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2400mg 3280mg 46hr (adjuvant FOLFOX)
    • 2022-08-31 - oxaliplatin 80mg/m2 110mg 2hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2400mg 3300mg 46hr (adjuvant FOLFOX)
    • 2022-08-31 - oxaliplatin 70mg/m2 70mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2400mg 3200mg 46hr (adjuvant FOLFOX)
    • 2022-06-27 - fluorouracil 200mg/m2 280mg 24hr D1-3 (adjuvant CCRT)
    • 2022-06-20 - fluorouracil 200mg/m2 280mg 24hr D1-5 (adjuvant CCRT)
    • 2022-06-13 - fluorouracil 200mg/m2 290mg 24hr D1-5 (adjuvant CCRT)
    • 2022-06-08 - fluorouracil 200mg/m2 290mg 24hr D1-3 (adjuvant CCRT)
    • 2022-05-30 - fluorouracil 200mg/m2 290mg 24hr D1-3 (adjuvant CCRT)
    • 2022-05-26 - fluorouracil 200mg/m2 290mg 24hr D1-2 (adjuvant CCRT)

==========

2022-10-03

[drug identification]

requesting drug identification for 3 items.

the 2 items are identified as following while the other 1 item remains unknown.

  • Vemlidy (tenofovir 25mg)
  • U-Cal (calcium carbonate 500mg)
  • Folic acid 5mg

these drugs will be sent back to ward by an in-hospital porter.

2022-05-30

[drug identification]

Total 3 drugs for identification.

The 2 identified items has been shown as following while the other 1 items still remain unknown:

  • A-Cal (calcium carbonate, CaCO3, 500mg)
  • Folic acid 5mg

These drugs will be sent back to ward by the in-hospital porter.

700054037

221003

  • diagnosis
    • Left pyriform sinus cancer, cT2N0M0, stage II status post laryngomicrosurgery on 2019-3-11 and complicated extraction of tooth*13 on 2019-03-13
    • Left tongue cancer, pT3N0M0, stage III, status post left tongue cancer excision and left neck dissection on 2019-02-22
    • Hypopharyngeal squamous cell carcinoma, moderately differentiated s/p laryngomicrosurgery on 2022-05-11, pT3N0M0, stage III and Tracheostomy + Port-A implantation on 2022-05-18
    • Carrier of viral hepatitis B
  • exam finding
    • 2022-08-11 PD-L1 (22C3)
      • Tumor Proportion Score (TPS) assessment: TPS < 1%
    • 2022-08-11 PD-L1 28-8 IHC
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percent of PD-L1 expression in tumor cells (TC): < 1%
    • 2022-08-11 PD-L1 (SP142)
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana) - S2022-8227
        • Tumor type: Squamous cell carcinoma
        • Tumor location: Hypopharynx
        • Testing assay: SP142 Assay (Ventana)
        • Testing platform: BenchMark XT
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
        • Control slide result: Pass,
        • Adequate tumor cells present (>=50 viable tumor cells): Yes,
      • Result:
          1. Tumor cell (TC) staining assessment: TC category: TC < 1%
          1. Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      • Note:
          1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
          1. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-08-04 Nasopharyngoscopy
      • smooth nasopharynx and oropharynx; regression of hypopharyngeal swelling compared to the previous study; thin mucosa over right arytenoid cartilage; right vocal cord fixation; fair left vocal cord movement.
    • 2022-07-28 MRI - larynx
      • Tongue cancer Stage IV, post chemotherapy * 3 cycles
      • Findings
          1. S/P opeation at left part of oral tongue and left neck.
          1. S/P tracheosotmy.
          1. Diffuse swelling at hypopharynx, mild regession as comapred with MRI on 20220505.
          1. No enlarged lymph node.
          1. No abnormality at nasopharynx, oropharynx and larynx.
          1. Mild hypertrophic degeneration of C-spine.
      • IMP:
        • Post-operation change at left part of oral tongue without evidence of recurrence. Less swelling of the hypopharynx, as compared with MRI on 20220505. Suggest regular follow-up.
    • 2022-05-25 ECG
      • Normal sinus rhythm
      • Cannot rule out Inferior infarct, age undetermined
    • 2022-05-25 CXR
      • S/P tracheostomy
      • S/P port-A implantation.
    • 2022-05-20 Tc-99m DMP whole body bone scan
      • In comparison with the previous study on 2019/02/14, no prominent change is noted in the lesions in the middle C-spine, lower T- and lower L-spines. Degenerative change may show this picture.
      • No prominent change is noted in the previous faint hot spot in the right temporal area of the skull, possibly more benign in nature.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
      • Increased activity in bilateral shoulders and knees, compatible with benign joint lesions.
    • 2022-05-19 Patho - stomach biopsy
      • Duodenum, 2nd portion, biopsy — Compatible with ulcer
      • Microscopically, the sections show a picture of mucosal erosion with inflammatory cells infiltrate, compatible with ulcer. Follow up
    • 2022-05-12 Patho - larynx biopsy
      • Hypopharynx, right, biopsy — Squamous cell carcinoma, moderately differentiated
      • Section shows a piece of squamous mucosa with infiltration of nests of neoplastic squamous cells.
      • The immunohistochemical stain of p16 is positive.
    • 2022-05-12 Patho - larynx biopsy
      • Esophagus, right, upper, posterior wall, biopsy — Squamous cell carcinoma, moderately differentiated
      • Section shows a piece of squamous mucosa with nests of neoplastic squamous cells in submucosa.
      • The immunohistochemical stain of p16 is positive.
    • 2022-05-05 MRI - larynx
      • The current study was compared to the prior one obtained on 2021/11/02.
      • Markedly enhancing mucosal thickening and swollen change of larynx and hypopharyngeal space. Suggest clinical correlation.
      • Post operative appearance in or at the area of left tongue, no focal mass or nodule.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
      • Normal appearance of both mastoid air-cells.
      • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
      • Clear appearacne of all paranasal sinuses.
    • 2021-11-02 MRI - larynx
      • Findings
        • Post operative appearance in or at the area of left tongue, no focal mass or nodule.
        • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
        • No evident abnormal enlarged lymph node in the visible neck.
        • Heterogeneous soft tissue in the right vocal cord, posterior wall of the bilaeral hypopharynx, righy hypopharynx and bilateral aryepiglottic folds, more on the right side, seems in progression.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • IMP:
        • Post OP at left tongue with left neck dissection. No local recurrence, no neck LAP
        • Seems in progression of bil. hypopharynx, larynx masses? need clinical check, partially due to post R/T effect?
    • 2021-07-15 MRI - larynx
      • Findings
        • s/p left neck lymph node dissection
        • heterogeneous enhancing soft tissue in the right vocal cord, posterior wall of the bilaeral hypopharynx, righy hypopharynx and bilateral aryepiglottic folds, more on the right side.
        • no neck LAP.
        • unremarkable change in the tongue.
        • unremarkable change at the skull base
      • IMP:
        • suspected tumors in the bilateral hypopharynx and right vocal cord.
    • 2019-02-22 Surgical pathology Level VI
      • pathologic diagnosis
        • Tongue, left, excision — Squamous cell carcinoma, moderately differentiated
        • AJCC Pathologic staging — pT3N0Mx, stage III at least
      • microscopic examination
        • Histologic Type: Squamous cell carcinoma with focal salivary gland invasion
        • Histologic Grade: G2: moderately differentiated
        • Microscopic Tumor Extension: 1.2 cm in thickness
    • 2019-02-18 Surgical pathology Level IV
      • pathologic diagnosis
        • Tumor, left pyriform sinus, biopsy — Squamous cell carcinoma
      • microscopic examination
        • Microscopically, the sections show a picture of squamous cell carcinoma characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with scant keratin formation.
        • Immunohistochemistry shows CK5/6(+); P63(+) and CK(+) for tumor cells.
    • 2019-02-15 Upper G-I panendoscopy
      • Diagnosis: suspect larynx lesion
      • Suggestion: suggest further study to check cancer or precancer lesion at larynx
    • 2019-02-14 Tc-99m MDP whole body bone scan
      • Increased activity in the middle C-spine, lower T- and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • A faint hot spot in the right temporal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and knees, compatible with benign joint lesion.
    • 2019-02-14 MRI - larynx
      • Left tongue CA, T3N0Mx stage III. Left pyriform sinus CA, T1N0Mx, stage I.
    • 2019-01-29 Surgical pathology Level IV
      • Tongue, lower, left, biopsy — Squamous cell carcinoma, p16(-)
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with stromal invasion and desmoplastic reaction. Subtle keratin formation is present.
      • IHC: p16(-).
  • consultation
    • 2022-05-16 Hemato-Oncology
      • Impression:
        • Squamous cell carcinoma, moderately differentiated, of the left oral tongue, s/p wide excision and left neck dissection, stage pT3N0(cM0), stage III, s/p radiotherapy.
        • Squamous cell carcinoma of the left pyriform sinus, stage cT2N0M0 (tumor board conclusion), s/p radiotherapy, with relapse.
        • HBV
      • Suggestion:
        • If sugical intervention is not feasible, CCRT is indicated. We would like to perform chemotherapy for this case.
        • Please arrange Port-A insertion for him.
    • 2022-05-13 Radiation Oncology
      • Q
        • This is a 54 y/o male patient with history of 1. Left oral tongue, SCC, moderately differentiated s/p wide excision and left neck dissection, stage pT3N0(cM0), stage III, s/p radiotherapy on 2019-05-20. 2. Left pyriform sinus SCC, stage cT2N0M0, Completion of radiotherapy on 2019-05-20, and HBV.
        • He was regularly followed up at our hospital. At Dr. Su’s OPD on 2022/05/03, PE showed no obivious palpable neck LN. Nasopharyngoscopy revealed posterior hypopharyngeal tumor with involvement of right pyriform sinus apex, with suspected esophageal involvement, and right vocal palsy. He was admitted underwent LMS tumor mapping on 20220511. The whole procedure performed smoothly. However, dyspnea noted since 20220512, we check nasopharyngoscope revealed right vocal palsy.
        • Hypopharyngeal cancer was suspected, but the pathology data pending.
        • It was explained by Dr. Wanfu Su that a tracheostomy was necessary in order to maintain a patent airway, and because the previous dose of radiotherapy had reached its upper limit, a total laryngectomy would be needed. Therefore, chemoradiotherapy may be indicated for the patient. Consult to determine this possibility.
      • A
        • S: For discussion the salvage treatment modality.
        • A:
          • Squamous cell carcinoma, moderately differentiated, of the left oral tongue, s/p wide excision and left neck dissection, stage pT3N0(cM0), stage III, s/p radiotherapy.
          • Squamous cell carcinoma of the left pyriform sinus, stage cT2N0M0 (tumor board conclusion), s/p radiotherapy, with relapse.
        • P:
          • According to HN tumor board (2022-05-13) conclusion, salvage surgery including tracheostomy is recommended.
          • The patient already received full dose radiotherapy before, further radiotherapy of previous irradiated area with low dose CCRT without surgery is only palliative and may be not effective. The possible effects of re-irradiation were well explained to the patient and his family. The patient would like to go back for consideration including neoadjuvant chemotherapy and then make a decision.
          • Please also consult medical oncologist.
  • surgical operation
    • 2022-05-18
      • Surgery
        • Tracheosotmy
      • Finding
        • Insertion of Shiley #6.
      • Procedure
        • The patient was in supine position with neck hyperextended. Skin was disinfected and draped as usual. Local anesthesia with Bosmin-rinsed Xylocaine was injected into the subcutaneous tissue and the pretracheal area layer by layer. A vertical skin incision was made in the midline of lower neck. Subcutaneous tissue, fascia and strap muscles were seperated, then the thyroid gland was seen and hooked upwards with thyroid hooks. The tracheal rings were cut in longitudinal direction. A oval-shaped window was made at the 2 nd to 3 rd rings. A Shiley #6 cuffed tracheostomy tube was inserted. The patient tolerated the above procedure well.
    • 2022-05-11
      • Surgery
        • Laryngomicrosurgery for tumor mapping      
      • Finding
        • upper esophageal posterior wall mass
        • hypopharyngeal (postcricoid) tumor, with right AE fold involvement
      • Procedure
        • The patient lay in supine position and general anesthesia was set up via EGTA. The neck was slightly extended with shoulder-roll. Rigid laryngoscope was applied gently with fixation of chest support. Microscope was use for the microlaryngoscopic procedure. Upper esophageal posterior wall mass and postcricoid tumor, with right AE fold involvement. Compression with Bosmin-rinsed cotton balls was used for hemostasis and removed thereafter. The patient standed the whole procedure well.   
    • 2019-03-13
      • Diagnosis
        • Deep caries of multiple teeth
      • PCS
        • 92014C
      • Finding
        • Multiple deep caries and retained roots of tooth 11,12,13,14,16,18,21,22,23,27,36,37 and 38.
      • Procedure
        • Patient was on a supine position and anesthetized through nasal endotracheal tube in the usual method.
        • Patient head was draped and nasal endotracheal tube was secured at the patient’s forehead area.
        • Patient’s mouth was soaked with aqueous b-iodine solution.
        • Patient’s mouth, lower face, neck and shoulder areas were disinfected with aqueous b-iodine solution
        • Patient’s body and head, except operation fields, were draped in the usual manner with 2-layer sterilized sheets.
        • Excess aqueous b-iodine solution in patients mouth was suctioned and a 4*8 gauze was placed at the patients throat to prevent fluid from entering patient’s airway.
        • Several cartridges of 1.8ml local anesthetic solution containing with 0.01mg epinephrine were injected into the operation fields for local hemostasis.
        • Complicated extraction of of tooth 11,12,13,14,16,18,21,22,23,27,36,37 and 38 was done carefully
        • Primary closure of the surgical wound with 3-0 and 4-0 Vicryl
        • After all the procedures were done, plenty of N/S was used to irrigate the oral cavity.
        • Patient regained consciousness smoothly and gradually after the operation was completed.
    • 2019-03-11
      • Diagnosis
        • Hypopharyngeal CA, Lt.
      • PCS
        • 66032B
      • Finding
        • FK oral retractor failed to approach left hypopharynx
        • LMS approach for tumor mapping, pyriform sinus posterior wall biopsy done
      • Procedure
        • The patient lay in supine position and general anesthesia was set up via EGTA. The neck was slightly extended with shoulder-roll. FK oral retractor was used first but failed to approach left hypopharynx. Rigid laryngoscope was applied gently with fixation of chest support. Microscope was use for the microlaryngoscopic procedure. left pyriform sinus posterior wall tumor mapping done by microforcep. Compression with Bosmin-rinsed cotton balls was used for hemostasis and removed thereafter. The patient standed the whole procedure well.
    • 2019-02-22
      • Diagnosis
        • left tongue cancer
      • PCS
        • 71013A
      • Finding
        • 1.7x1.5x1.2cm tumor at the junction of left mouth floor and ventral tongue, excision with adequate safty margin.
        • Excision of left neck lymph nodes from level I to level IV.
        • IJV, SAN and SCM were preserved well.
      • Procedure
        • He was in supine position with neck hyperextended. General anesthesia was set via nasal endotracheal tube. Then he was disinfected and draped as usual. The skin incision with neck and lower lip extension was made. The left side skin flaps were developed in the subplatysmal plane as far as the midline neck anteriorly, trapezius muscle laterally, clavicle inferiorly, and mandible superiorly. After the flaps were completely elevated, the SCM muscle was dissected out, then the whole lymphoareolar tissue with the lymph nodes were dissected carefully off the carotid artery sheath. Several lymph nodes were noted at level IV, III,II, The internal jugular vein, vagus nerve and spinal accessory nerve were identified and preserved, One JP ball was inserted for drainage and the wound was closed in 2 layers. Thee the oral cavity was disinfected and irrigated. The tumor invaded the junction of mouth floor and left ventral tougue. The whole tongue and mouth floor was removed as a whole with adequate safty margin. After hemostasis, the tongue was sutured anteriorposteriorly, NG tube was inserted for feeding.
  • chemoimmunotherapy
    • 2022-09-30 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
    • 2022-09-01 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
    • 2022-08-10 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
    • 2022-07-15 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
    • 2022-06-23 - docetaxel 60mg/m2 100mg 1hr D1 + cisplatin 60mg/m2 100mg 24hr D1 + fluorouracil 750mg/m2 1300mg 24hr D1-5
    • 2022-06-09 - docetaxel 35mg/m2 60mg 1hr D1 + cisplatin 30mg/m2 50mg 2hr D1 + fluorouracil 2000mg/m2 3500mg 46hr
    • 2022-06-02 - docetaxel 35mg/m2 60mg 1hr D1 + cisplatin 30mg/m2 50mg 2hr D1 + fluorouracil 2000mg/m2 3500mg 46hr

[note]

Locally advanced squamous cell carcinoma of the head and neck ( https://www.uptodate.com/contents/locally-advanced-squamous-cell-carcinoma-of-the-head-and-neck-approaches-combining-chemotherapy-and-radiation-therapy )

  • Systemic Therapy Regimen
    • Agents with proven activity in squamous cell head and neck cancer that are most commonly included in either induction or concurrent chemotherapy regimens include the platinum compounds (cisplatin, carboplatin), fluorouracil, and taxanes (docetaxel, paclitaxel).
    • Induction chemotherapy - Multiple clinical trials have established that three drug combinations of cisplatin, fluorouracil, plus a taxane are the preferred approach for induction chemotherapy.
      • Initial clinical trials found that cisplatin and fluorouracil (PF; cisplatin, 100 mg/m2, and fluorouracil, 1000 mg/m2/day continuous 24-hour infusion for five days) given every three weeks as induction chemotherapy induced higher rates of complete response and better survival compared with two cycles of an earlier cisplatin and bleomycin-based regimens or regimens using two cycles of cisplatin with shorter infusions of fluorouracil.
      • Subsequent randomized trials found that the addition of a taxane (docetaxel, paclitaxel) to PF induction chemotherapy enhanced the effectiveness of induction chemotherapy used with radiation therapy (RT) alone or with RT plus concurrent chemoradiation. In contrast, a small randomized trial in larynx/hypopharynx cancer did not show a benefit from the addition of cetuximab to induction chemotherapy that included docetaxel and cisplatin followed by accelerated RT with or without concurrent cetuximab.

[assessment]

  • Nincort Oral Gel (triamcinolone) is used for the treatment of chemotherapy-induced oral ulcers, while Baraclude (entecavir) is utilized for the treatment of HBV infections.
  • The laboratory results on 2022-09-27 were grossly normal except for a slight pancytopenia.

chemotherapy induced oral ulcer is treated with Nincort Oral Gel (triamcinolone) and hepatitis B is surpressed using Baraclude (entecavir)

700358478

221003

{Adenocarcinoma of splenic flexure colon with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC status post colostomy on 2021-10-06}

  • exam findings
    • 2022-09-01, -08-15 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
      • Findings
        • The NCV study showed slowing sensory conduction velocity in bilateral ulnar nerves. The F wave study showed prolonged latency in left tibial nerve. The H reflex study showed both prolonged.
      • Conclusion
        • The above findings suggest bilateral ulnar neuropathy and bilateral lumbosacral radiculopathy. Advise clinical correlation.
    • 2022-08-16 MRI - brain
      • Known a case of colon cancer. No metastatic lesion of brain parenchyma.
      • Moderate periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
      • Short segmental moderate stenosis of left distal ICA (cavernous segment).
    • 2022-07-14 CT - abdomen, pelvis
      • S/P colon operation. Mild decreased size of lung and liver metastases. Multiple bony metastases.
      • Enlargement of prostate. Mild dilatation of abdominal aorta (3.8cm) with mural thrombus.
    • 2022-06-27 CT - lung/mediastinum/pleura
      • Findings
        • Lungs:
          • multiple randomly distributed pulmonary nodules of varying sizes (up to 13mm at lingula, lower lobes predominance) due to metastases.
          • extensive, bilateral upper lobe predominant, centrilobular emphysema, in the lungs. and subpleural paraseptal emphysema
          • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
        • Mediastinum and hila: no enlarged LN or mass.
        • Vessels: moderate coronary arterial calcification
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: no effusion or nodule.
        • Chest wall and visible lower neck: diffuse blastic change in bones of thoracic cage, with focal expansile blastic change of left 5th rib.
        • Visible abdominal contents: small metastatic lesions in the liver.
      • Impression:
        • colon cancer with lung, liver, and bones metastases, in progression of lung metastases compared with CT on 2022/04/15
    • 2022-06-16 CXR
      • S/P port-A implantation.
      • Multiple osteoblastic bony metastases in the ribs and spine are noted.
      • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-04-16 Chest AP - portable
      • S/P port-A implantation.
      • Multiple osteoblastic bony metastases in the ribs and spine are noted.
      • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-04-15 CT - abdomen, pelvis
      • Splenic flexure colon cancer with multiple metastatic nodes in the adjacent omentum and mesentery, multiple metastases in the liver, lung and bone S/P C/T show partial response.
      • RCC 2.4 cm at left kidney lower pole shows stationary.
      • The differential diagnosis include angiomyolipoma (lipid-poor). Follow up is indicated.
    • 2022-03-31 Chest PA erect view
      • Multiple osteoblastic bony metastases in the ribs and spine are noted.
      • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-03-11 Bronchial dilation test
      • Moderate obstructive ventilatoryimpairment without significant reversibility
      • FEV1/FVC = 45%, FVC = 96%, FEV1 = 54%
    • 2022-03-10 Chest PA
      • Multiple osteoblastic bony metastases in the ribs and spine are noted.
      • A nodular opacity projecting in the left lower lung is suspected.
    • 2022-01-19 CT
      • Findings:
        • Prior CT identified lobulated segmental wall thickening in the splenic flexure colon is noted again, mild decreasing in size.
          • In addition, prior CT identified multiple metastatic nodes in the surrounding mesentery and omentum are noted again, decreasing in size.
        • Prior CT identified mutliple metastases on both hepatic lobes are noted again, decreasing in size.
          • The size of S5 metastasis in prior and current CT is measured 3.1 cm and 2.5 cm, respectively.
        • Prior CT identified mutliple metastases on both lung are noted again, decreasing in size.
          • The size of LUL metastasis in prior and current CT is measured 2 cm and 1.5 cm, respectively.
        • Prior CT identified multiple osteoblastic bony metastases in the L-spine and bilateral ilium are noted again, increasing density that may be bony metastases with progressive disease.
        • Prior CT suspected renal cell carcinoma measuring 2 cm in left kidney lower pole is noted again, stable in size.
          • The differential diagnosis include angiomyolipoma (lipid-poor).
        • Abdominal aorta aneurysm measuring 3.3 cm in diameter with atherosclerotic change and mural thrombosis is noted.
          • Right common iliac artery also shows aneurysm 1.7 cm in diameter with mild mural thrombus formation.
        • Adenoma 0.9 cm in left adrenal gland it noted.
      • Impression:
        • Splenic flexure colon cancer with multiple metastatic nodes in the adjacent omentum and mesentery, and multiple metastases in the liver and lung S/P C/T show partial response.
        • Multiple bony metastases show more osteoblastic change.
        • RCC 2 cm at left kidney lower pole shows stationary. The differential diagnosis include angiomyolipoma (lipid-poor). Follow up is indicated.
    • 2021-09-29 CT
      • Findings:
        • There is lobulated segmental wall thickening in the splenic flexure colon measuring 1.7 cm in wall thickness, causing lumen narrowing that is compatible with adenocarcinoma with impending obstruction.
          • In addition, there are multiple metastatic nodes in the surrounding mesentery and omentum, and the largest one 2.2 cm.
        • There are mutliple poor enhancing masses on both hepatic lobes and the largest one measuring 3.1 cm in S5 that are compatible with liver metastases.
        • There are several osteoblastic change of the L-spine and bilateral ilium that are compatible with bony metastases.
        • Abdominal aorta aneurysm measuring 3.3 cm in diameter with atherosclerotic change and mural thrombosis is noted.
          • Right common iliac artery also shows aneurysm 1.7 cm in diameter with mild mural thrombus formation.
        • There are few small soft tissue nodules in both lower lung that are compatible with lung metastases.
        • There is a well-defined heterogeneous poor enhancing mass measuring 2 cm in left kidney lower pole that may be RENAL CELL CARCINOMA. The differential diagnosis include metastasis.
          • Please correlate with contrast enhanced dynamic CT or MRI.
        • Adenoma 0.9 cm in left adrenal gland it noted.
        • Imaging stage: T3N2bM1c stage IVC
    • 2021-09-28 Patho - Colon biopsy
      • Colon, splenic flexure, biopsy - Adenocarcinoma, moderately differentiated
      • The secvtions show a picture of adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular patterns with desmoplastic stromal reaction.
      • IHC, tumor cells reveal: EGFR(-), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2021-09-23 CT
      • Imaging stage: T4N2M1
      • Imp: Colon cancer at splenic flexure with liver, lung and bone mets.
  • consultation
    • 2022-08-13 Neurology
      • Q
        • This 73 year-old man patient is a case of Colon cancer with obstruction and splenic, liver, lung and bone metastases, T3N2bM1b, stage IVB s/p T loop colostomy on 2021/10/06 s/p chemotherapy with FOLFIRI/Avastin, SD. He was admitted for palliative chemotherapy with Avastin(C16)/FOLFIRI(C10D1) from 2022/08/12~2022/08/14.
        • This time, dizziness with bilateral lower limbs weakness for 2 months. Now, for evaluate examination of dizziness with bilateral lower limbs weakness. Thank you.
      • A
        • The patient had chronic unsteady gait.
          • Cranial nerve: intact
          • motor: intact
          • sensory: intact
          • Romberg (+)
          • FNF: bilateral dysmetria
        • Imp:
          • suspect cerebellar dysfunction + suspected peripheral sensory nerve disease
        • P:
          • Arrange brain MRI with/without contrast if no contraindication.
          • Arrange NCV upper and lower limbs (motor + sensory + F + H)
          • Try suzin 1# HS
          • Check TSH, Free T4, ANA, HbA1C, Anti SSA/SSB, Vit B12, folic acid
    • 2022-03-14 Thoracic Medicine
      • Underlying disease:
        • Colon cancer with multiple lung meta, ribs mets, bone mets, cT3N2M1c, stage IV
        • Heavy smoking (quited), with COPD, centrilocular emphysema, PFT showed: moderate obstruction, involving both large and small sized airways
        • Baseline hypoxemia, room air SaO2 only 94%
        • Old TB with LUL calcinfied granuloma.
      • Suggestion:
        • Favor chest tight due to (1) rib mets with pain, (2) COPD, (3) abdominal distension with diaphragm dysfunction, (4) possibly GERD
        • Add Foster 2 puff BID, spiriva 2 puff HS (from Adult-Aerochamber)
        • Self-paid Adult-Aerochamber recommended
        • Try Topaal for GERD
        • Pain relief
        • Avoid constipation
  • surgical operation
    • 2021-10-06 T loop colostomy
      • Splenic flexure colon cancer with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC
      • RUQ stoma with stent
    • 2017-12-11 Biopsy prostate (punch)
      • Prostatic hyperplasia with urinary retention
      • Finding
        • DRE: stiffness Rt> Lt but not hard nodule, may be huge adenoma
        • Hypertrophy of prostate with high bladder neck, enlarged median lobe
        • Moderate trabeculation of bladder
        • intraoperative impression: prostate volume >100cc
        • 52g retrieved
  • chemotherapy regimen
    • 2022-09-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
    • 2022-09-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
    • 2022-08-26 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
    • 2022-08-12 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
    • 2022-07-28 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
    • 2022-07-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
    • 2022-06-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4700mg 46hr
    • 2022-06-16 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
    • 2022-06-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
    • 2022-05-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 750mg 2hr + 5-Fu 400mg/m2 750mg 10min + 5-Fu 2400mg/m2 4500mg 46hr
    • 2022-04-27 - irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2022-04-15 - irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2022-03-29 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2022-02-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2022-01-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2022-01-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2021-12-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2021-12-09 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2021-11-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2021-11-12 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr
    • 2021-10-26 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 300mg/m2 10min + 5-Fu 2400mg/m2 46hr
      • Ref UpToDate - FOLFIRI plus bevacizumab chemotherapy for metastatic colorectal cancer

==========

2022-10-03

  • Irinotecan has been reported with following adverse drug reactions and incidences: dizziness (15% to 21%), drowsiness (9%).
  • Neurology studies on 2022-09-01 showed slowing sensory conduction velocity in bilateral ulnar nerves and prolonged latency in left tibial nerve.
  • A walking stick is being prepared by the Discharge Planning Service Center.

2022-09-08

  • It is recommended to prescirbe the patient-carried diphenidol (25mg/tab) 1# TIDPC (currently TID) according to the package insert.

2022-06-30

  • 2022-06-27 CT showed lung mets in progression, however tumor markers decreased slightly (CEA: 2022-06-24 2235 ng/mL <- 2022-06-14 2447 ng/mL; CA199: 2022-06-24 3344 U/mL <- 2022-06-14 3614 U/mL).
  • Lung mets have been developed. Oxaliplatin is rarely associated with pulmonary toxicity. For patients with unexplained pulmonary symptoms, oxaliplatin is recommended to be withheld until interstitial lung disease or pulmonary fibrosis is excluded.

2022-06-17

  • A partial response was seen on the CT image of 2022-04-15 (compared to 2022-01-19), however some biomarker levels have continued to rise.
  • Biomarkers time series:
    • CEA
      • 2022-06-14 2447 ng/mL
      • 2022-05-25 2039 ng/mL
      • 2022-04-27 2063 ng/mL
      • 2022-03-30 3132 ng/mL
      • 2022-02-16 1956 ng/mL
      • 2022-01-18 771 ng/mL
    • CA199
      • 2022-06-14 3614 U/mL
      • 2022-05-25 2383 U/mL
      • 2022-04-27 2758 U/mL
      • 2022-03-30 2837 U/mL
      • 2022-02-16 2376 U/mL
      • 2022-01-18 1089 U/mL
  • The creatinine level on 2022-06-14 increased to 1.43 mg/dL slightly above ULN and a record high, which might need to be kept in check.
  • SpO2 96%, TPR, BP were stable since this hospitalization. No issue with active prescription.

2022-06-02

  • During the past five months, the patient’s body weight has increased by more than ten kilograms (84.2 kgw 2022-06-01 <- 71.5 kgw 2022-01-05), and insomnia remained on the patient’s medical problem list in recent hospital stays even when lorazepam has been prescribed. The use of steroids (both systemically and inhalationally) can result in these side effects.
  • Pharmacotherapy should not be the sole treatment of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is the preferred first-line treatment for chronic insomnia in adults. The evidence base is stronger for CBT-I than for medications. When used, medications should be combined with healthy sleep habits and CBT-I, when appropriate and available.

2022-04-28

  • Recent two consecutive CT scans have indicated a partial response of splenic flexure colon cancer to the current regimen. However, there is an enlarged tumor on the lower pole of the left kidney that might need to be addressed (2.4cm 2022-04-15 <- 2.0cm 2022-01-19, a 20% increase in diameter in 3 months).
  • The CEA and CA199 levels on 2022-04-27 fell to 2063ng/mL (from 3132ng/mL on 2022-03-30) and 2758U/mL (from 2837U/mL on 2022-03-30), which were both positive signs.
  • In three months, the body weight increased by ten kilograms (81.2 kgw 2022-04-27 <- 71.5 kgw 2022-01-05). According to lab data on 2022-04-27, liver and kidney function, serum electrolytes, and blood cell counts were all within normal ranges. Cachexia is still a diagnosis.
  • The current chemotherapy regimen FOLFIRI plus bevacizumab is generally well tolerated by the patient and respiratory symptoms have been managed with corresponding medication.

2022-04-15

  • Currently there are no new CT images (last 2022-01-19) or CEA or CA199 readings (last 2022-03-30) since the last hospitalization.
  • Lab results on 2022-04-12 concerning liver function, renal function, serum electrolytes, and blood cell counts were grossly normal.
  • The current chemotherapy regimen FOLFIRI is generally well tolerated by the patient and respiratory symptoms have been managed with corresponding medication.

2022-03-30

  • The evidences were inconsistent, with CT images (2022-01-19) showing improvement and lab data readings (CEA from 869 to 3132 ng/mL, CA199 from 1089 to 2837 U/mL, since 2022) showing deterioration, following T loop colostomy (2021-10-06) and FOLFIRI plus bevacizumab (since mid Nov 2021).
  • pMMR (colon biopsy pathology 2021-09-28), certain kind of drugs e.g. nivolumab or pembrolizumab might not be preferred.
  • Cetuximab or panitumumab may be appropriate in this patient with a left-sided tumor if the RAS WT is confirmed.
  • When BRAF V600E mutation is proven, then BRAF inhibitors, e.g. encorafenib, dabrafenib + trametinib, could also be considered optionally.

2022-02-17

  • CT images on 2022-01-19 showed some improvement based on decreasing in mass size and/or density, CEA and CA199 data revealed the same trend p/s colostomy and FOLFIRI treatment, however both the lab readings doubled within just a month could hint the disease is acquiring resistence after 4 months treatment.
  • pMMR, certain kind of drugs e.g. nivolumab or pembrolizumab might not be preferred.
  • if RAS WT proven, cetuximab or panitumumab might be applicable for this left-sided tumor patient.

701179785

221003

{vancomycin trough concentration}

  • There was a trough concentration of 9.4 mg/L recorded on 2022-10-03 in this patient treated with U-Vanco (vancomycin) 1000mg QW15 (based on his renal function) since 2022-09-25.

  • It appeared to be effective (CRP 15.84mg/dL 2022-10-03 <= 29.58mg/dL 2022-09-22) when vancomycin was used, however, it is recommended that serum vancomycin trough concentrations should always be kept above 10 mg/L to avoid resistance development. For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC (Area under the curve): MIC of 400. (ref: Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society Of Infectious Diseases Pharmacists. Clin Biochem Rev. 2010;31(1):21-24.)

  • Changing the current administration frequency from QW15 to QW135 is recommended to increase the concentration to at least 10 mg/L. Thank you!

700052326

220930

  • BH 172, BW 109.2, BMI 36.9

  • past history

    • 3-V coronary artery disease
      • s/p PTCA with stenting for 2 times in 2005-10 & 2006-02 at Cardinal Tien Hospital;
      • s/p PTCA with stenting for LAD instent restenosis in 2006-08 at TPE TCH;
      • s/p PTCA with bare-metal stenting for RCA and LAD on 2011-09-28;
      • s/p PTCA with stenting for middle RCA and PL branch on 2012-02-08;
      • s/p PTCA with stenting for D1 & LAD on 2012-09-05.
      • 2VD with LAD-D1 and RCA stenosis on 2015-06-01, Medical treatment was suggested due to no severe stenosis or occlusion was found.
    • Hypertensoin under medical control for 10+ years
    • Hyperlipidemia under statin control for 10+ years
    • Type II DM for years
    • Old left radial liniar fracture
    • Diverticulitis of ascending colon and local perforation with conservation treatment on 2022-01.
  • family history

      1. Father died of acute myocardial infarction at age 64, hypertension with diabetes.
      1. Grandfather and younger brother: heart disease, unknown type.
      1. Mother: hypertension.    
  • lab data

    • CEA
      • 2022-09-27 CEA 6.67 ng/mL
      • 2022-08-30 CEA 9.69 ng/mL
      • 2022-08-03 CEA 14.95 ng/mL
      • 2022-07-05 CEA 20.39 ng/mL
      • 2022-06-07 CEA 22.12 ng/mL
      • 2022-05-04 CEA 27.26 ng/mL
      • 2022-04-01 CEA 39.36 ng/mL
      • 2022-03-25 CEA 38.05 ng/mL
    • All-RAS
      • 2022-04-29 Detected
        • KRAS codon 12 GGT > GCT, p.G12A
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment.
          • Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF
      • 2022-04-29 Not Detected
        • There was no variant detected in the BRAF gene
          • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment.
          • Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • exam finding

    • 2022-08-31 CT - abdomen
      • History:
        • Recurrent RUQ pain for times, intermittent
        • 20220111 CT: Diverticulitis of ascending colon with perforation and abscess s/p medication (0111~0120) and LGI bleeding (0124~0126)
        • 20220401 CEA: 39.36 ng/mL (< 5).
        • 20220401 CT: Locally advanced ascending colon cancer with abscess and partial obstruction, carcinomatosis s/p exploratory laparotomy with right hemicolectomy on 2022/04/06, pT4aN2bM1c, Stage IVC
      • Findings:
        • S/P right hemicolectomy
        • Prior CT identified multiple enlarged nodes in celiac trunk, hepatoduodenal ligament, mesentery, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain and bilateral interal iliac chain are noted again, mild decreasing in size that are c/w metastatic nodes (non-regional) S/P C/T with partial response.
        • A hepatic cyst measuring 1.3 x 0.7 cm in S3 is noted.
      • Impression:
        • Non-regional metastatic nodes S/P C/T show partial response.
        • Detailed findings, please see description.
    • 2022-05-11 Chest XR
      • S/P Port-A infusion catheter insertion.
      • Normal appearance of trachea and bil. main bronchus.
      • Normal size of heart.
      • Clear both lung field.
    • 2022-04-08 Chest XR
      • Right catheterization to SVC in position.
      • S/P NG tube indwelling.
      • Ground glass opacities in bil. lungs.
      • S/P operation.
    • 2022-04-07 Patho - colon segmental resection for tumor
      • pathologic diagnosis
        • Ascending colon, right hemicolectomy — Adenocarcinoma, poorly differentiated, with abscess formation
        • Resection margins, right hemicolectomy — Free
        • Lymph nodes, mesocolic, right hemicolectomy — Metastatic adenocarcinoma (7/14)
        • Pathology stage: pT4aN2b(cM1a); Stage IVA
      • microscopic examination
        • Histology: Adenocarcinoma with abscess formation
        • Histology Grade: Poorly differentiated
        • Depth of invasion: Pericolic soft tissue
        • Angiolymphatic invasion: Present and extensive
        • Perineural invasion: Present
        • Tumor cell budding: High
        • Margins
          • Proximal and distal margins: Uninvolved
          • Circumferential (radial) margin: Uninvolved
        • Lymph node metastasis, mesocolic: Metastatic adenocarcinoma (7/14)
        • Extranodal involvement: Present
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • Primary Tumor (pT): pT4a (Tumor invades through serosa)
          • Regional Lymph Nodes (pN): pN2b (seven or more regional lymph nodes are positive)
          • Distant Metastasis (pM): cM1a
        • Type of polyp in which invasive carcinoma arose: Not identified
        • Additional pathologic findings: Two tubulovillous adenoma and tumor emboli in submucosal vascular channels
        • Tumor regression grading S/P CCRT: N/A
        • IHC: EGFR(+), MLH1(+), PMS2(focal +), MSH2(+), MSH6(+)
        • Appendix: Submucosal abscess and granulation tissue
    • 2022-04-07 Chest XR
      • S/P ET tube inserted in position with cuff inflation.
      • Right catheterization to SVC in position.
      • S/P NG tube indwelling.
      • Right pleural effusion.
      • Ground glass opacity in bilateral lower lungs.
    • 2022-04-04 CT - abdomen, pelvis
      • Findings:
        • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Enlarged LNs at mediastinum and along aorta/ IVC and bil. iliac vessels.
        • Grade 4 fatty liver.
        • Normal appearance of spleen, pancreas, adrenals and kidneys.
        • Distention of gallbladder.
        • Intact bony structures.
        • Minimal ascites.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • Atherosclerosis of coronary arteries.
        • Partial atelectasis at right basal lung.
      • Impression:
        • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Enlarged LNs at mediastinum and along aorta/IVC and bil. iliac vessels.
        • Grade 4 fatty liver.
        • Distention of gallbladder.
    • 2022-04-03 Electrocardiography, ECG
      • Sinus rhythm with Premature atrial complexes
      • Moderate voltage criteria for LVH, may be normal variant
      • Anteroseptal infarct
      • T wave abnormality, consider lateral ischemia
    • 2022-04-01 CT - abdomen, pelvis
      • Findings:
        • There is lobulated enhancing wall thickening at the ascending colon that may be adenocarcinoma. The differential diagnosis include diverticulitis. Please correlate with colonoscopy. In addition, there are multiple enlarged nodes in right side mesocolon (the largest one measuring 2.8 cm) and mesentery root that may be metastatic nodes?
        • There are multiple enlarged nodes in celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain and bilateral interal iliac chain. Metastatic nodes (non-regional) are highly suspected.
        • There is symmetrical wall thickening of the ascending colon with surrounding fatty stranding and free gas bubbles that is c/w prior acute diverticulitis with perforation and abscess S/P treatment with residual change. In addition, The free gas bubbles show directly attached right transverse abdominis muscle that may be muscle invasion.
        • A hepatic cyst measuring 1.3 x 0.7 cm in S3 is noted.
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Adenocarcinoma of the proximal ascending colon with lymph nodes metastases is highly suspected.
        • If ascending colon cancer is finally proved by pathology. According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for colon cancer: T4a N2b M1a, Stage:IVA
    • 2022-01-25 Sigmoidoscopy
      • Indication:Blood in the stool
      • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
      • Anesthesia: No anesthesia
      • The scope reach the sigmoid colon. Multiple diverticula at S colon
      • Internal hemorrhoid was noted.
      • Diagnosis
        • Diverticulosis, S colon
        • Internal hemorrhoid
      • Complication
        • No immediate complication
    • 2022-01-11 CT - abdomen, pelvis
      • Findings
        • Wall edema at ascending colon with pericolonic fatty infiltrates and fluid, suspected ascending colon diverticulitis.
        • There are outpouching lesions in the sigmoid colon, suggesting sigmoid diverticulosis.
        • Presence of gallbladder sludge.
        • Liver cyst, 1.3cm in left lobe liver.
        • Unremarkable change of the spleen, pancreas and both kidneys.
        • There are multiple enlarged lymph nodes in the paraaortic region and common iliac and obturator regions. suspected lymphoma.
      • Impression:
        • Colon diverticulosis.
        • Suspected ascending colon diverticulitis, suggest clinical correlation.
        • Multiple enlarged lymph nodes in the paraaortic region and common iliac and obturator regions. Suspected lymphoma. Suggest further study.
      • Imaging Report Form for Colorectal Carcinoma
        • Imaging stage: T4aN2M1a, stage IVA
    • 2021-11-12 Myocardial perfusion SPECT with persantin
      • The Tl-201 stress myocardial perfusion SPECT performed after intravenous injection 60 mg of dipyridamole revealed markedly decreased perfusion of radioactivity to the apex, inferoapical wall and anterior wall and mildly to moderately decreased perfusion of radioactivity to the septum, inferolateral wall and posterior wall. The Tl-201 redistribution myocardial perfusion SPECT revealed partial reperfusion of radioactivity to the apex, inferoapical wall and anterior wall and reperfusion of radioactivity to the septum, inferolateral wall and posterior wall.
      • IMPRESSION: Probably severe myocardial ischemia with possible a portion of infarction at the apex, inferoapical wall and anterior wall and mild to moderate myocardial ischemia at the septum, inferolateral wall and posterior wall.
    • 2021-11-12 2D transthoracic echocardiography
      • Mildly abnormal LV systolic function with hypokinesia to akinesia of mid-anterior to apical segments
      • Dilated LA and LV
    • 2021-10-26 Electrocardiography, ECG
      • Normal sinus rhythm
      • Anteroseptal infarct, age undetermined
    • 2017-11-10 Renal ultrasound
      • Bilateral parenchymal renal disease.
  • consultation

    • 2022-04-09 Infectious Disease
      • Findings:
        • Consultation for Finibax antibiotic
        • A-colon cancer with local abscess and partial obstruction case.
        • Fever persists for nearly one week despite Brosym use.
        • Serial CxR film shows newly developed right pleural effusion and LLL infiltrates, which hard to say pneumonia or not.
        • No significant culture report available yet.
        • White count 15110 yesterday and CRP level up to 26 today.
        • Brosym is replaced by Finibax ysterday.
      • Suggestion:
        • Continue Finibax for 5 days first.
        • Check drainage fluid and blood culture report.
  • multiteam

    • 2022-04-07 Social Service
      • Reason: Economic issues such as medical care, nursing care, daily necessities, etc.
      • Processing status: open
      • Family status: 20220406 Talk with the case brother
        • The case is unmarried. After the stent was installed in the heart in 2013, he is unemployed and his last job is a car salesman.
        • The family has a history of heart disease. His grandfather, his father, his elder brother and his elder sister all died of heart disease. The mother of the case is 84 years old and has four sons and two daughters. The case is ranked fifth, and they are twin brothers. The second brother of the case, married and living in Linkou, was estranged from the case’s family and did not provide assistance. The second sister of the case is married and works as a general electronics company operator. The brother-in-law of the second sister is a bus driver. The two have a son. The nephew of the case is married and has a young son.
        • The case does not have labor insurance and private insurance, and the house is owned by the case and the case brother.
        • The younger brother is a Reha bus driver with a monthly income of about 33,000 yuan. After the case fell ill, the second sister assisted in taking out medical insurance and had a heart stent installed in our hospital. The case and the mother’s living expenses all depend on the younger brother’s income. .
      • Main Issue: Economic Issue
    • 2022-04-06 PreOp Evaluation
      • Fever before operations: No  
      • CNS:Consciousness: Clear and alert  
      • Respiratory system: Lung disease: No
      • Breathing sound: Clear
      • Cardiovascular System: Cardiovascular disease: Yes
      • Diabetes mellitus: Yes, Good control
      • Malignant neoplasm: No
      • Bleeding tendency: Nil  
      • Other infectious disease: No
      • Plavix discontinued for 3 months   
  • surgical operation

    • 2022-04-06
      • Surgery
        • EXP LAP with right hemicolectomy
      • Finding
        • A colon tumor with invasion to right side abdominal wall, with abscess, invade to gerota fascia, colohepatic ligment and partial obstruction.
        • Enlarge LN over ileocecal artery
        • Tumor invasion to ileum.
  • radiotherapy

    • 2022-06-28 ~ 2022-07-22 CCRT 5000cGy/25 fractions (15 MV photon) to PA & pelvic LAPs
  • chemoimmunotherapy

    • 2022-09-29 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 190mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-08-30 - oxaliplatin 85mg/m2 190mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-08-18 - oxaliplatin 85mg/m2 190mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-08-05 - oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-07-22 - oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-07-07 - oxaliplatin 75mg/m2 170mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2700mg 24hr D1-2
    • 2022-06-23 - oxaliplatin 65mg/m2 150mg 2hr + leucovorin 400mg/m2 900mg 2hr + 5-Fu 1200mg/m2 2800mg 24hr D1-2
    • 2022-06-09 - leucovorin 400mg/m2 950mg 2hr + 5-Fu 1200mg/m2 2800mg 24hr D1-2
    • 2022-05-26 - leucovorin 400mg/m2 950mg 2hr + 5-Fu 1200mg/m2 2800mg 24hr D1-2

==========

2022-09-30

  • A mild pancytopenia was observed on 2022-09-27, but the scheduled chemotherapy should not be suspended
  • The underlying conditions T2DM and HTN appeared to be under control during this hospitalization.
  • A downward trend in CEA levels has been observed, which is encouraging and suggests the current regimen is working.
    • 2022-09-27 CEA 6.67 ng/mL
    • 2022-08-30 CEA 9.69 ng/mL
    • 2022-08-03 CEA 14.95 ng/mL
    • 2022-07-05 CEA 20.39 ng/mL
    • 2022-06-07 CEA 22.12 ng/mL
    • 2022-05-04 CEA 27.26 ng/mL
    • 2022-04-01 CEA 39.36 ng/mL

2022-08-31

  • In patients with renal failure (acute or chronic), the renal clearance of metformin is decreased, and there is an associated risk of lactic acidosis. Some patients who receive intravenous contrast may experience a deterioration of renal function (contrast-induced nephropathy). Intravenous studies using a single dose of metformin in normal subjects show that metformin is excreted as unchanged drug in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) or biliary excretion. The patient does not appear to have renal impairment (2022-08-30 creatinine 0.59 mg/dL, eGFR 154.55, BUN 12 mg/dL). For CT scanning, metformin might be temporarily held, although the risk of lactic acidosis is less likely to occur in this patient.
  • Dapagliflozin is primarily glucuronidated to become the inactive 3-O-glucuronide metabolite (60.7%). The metabolites are mainly inactive, although dapagliflozin is not recommended in patients with a creatinine clearance below 45mL/min and is contraindicated in patients with creatinine clearance below 30mL/min, temporarily hold the drug for CT scanning could be a preventive option which might be over aversion to the risk.

2022-08-19

  • There was a study demonstrated that empirically eliminating 5-FU bolus and LV from first line palliative therapy with mFOLFOX6 in mCRC resulted in no significant difference in median PFS or OS. Despite reduced growth factor utilization, the non-bolus arm demonstrated a favorable safety profile with less treatment-related hematologic grade >= 3 AE. It suggested consideration of empirically eliminating 5-FU bolus and LV from the mFOLFOX6 regimen to avoid additive toxicities without negatively impacting efficacy. Reference: Impact of empirically eliminating 5-fluorouracil (5-FU) bolus and leucovorin (LV) in patients with metastatic colorectal cancer (mCRC) receiving first-line treatment with mFOLFOX6. DOI: 10.1200/JCO.2020.38.15_suppl.4022 Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020) 4022-4022. https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.4022
  • Because this patient is receiving a 5-FU-bolus-removed regimen, leucovorin might also be removed or reduced to no more than 200mg/m2.

2022-07-25

  • The patient was admitted to receive his scheduled FOLFOX regimen.
  • Cardiovascular adverse reactions reported for oxaliplatin include chest pain (5%), edema (10%), flushing (3%), peripheral edema (5%), and thromboembolism (2%); and for fluorouracil, angina pectoris, cardiac arrhythmia, cardiac failure, cerebrovascular accident, ischemic heart disease, local thrombophlebitis, myocardial infarction, vasospasm, and ventricular ectopy.
  • For this patient with a history of previous myocardial infarction and chronic ischemic heart disease, oxaliplatin is titrated up from 65 mg/m2 to 75 mg/m2 (still less than the standard 85 mg/m2), and the 5-Fu bolus is skipped.
  • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. There is no abnormality in the serum potassium level (2022-07-19), which was 3.5 mmol/L. Earlier ECG 2022-04-03 showed: 1) Anteroseptal infarct; 2) T wave abnormality, consider lateral ischemia.
  • CEA and CA199 keep declining since April 2022. 2022-07-05 CEA 20.39 ng/mL (<- 38) , CA199 12.38 U/mL (<- 20).
  • The patient’s blood sugar level fluctuates between 89 and 147 mg/dL, never exceeding 150 mg/dL during this hospitalization. There is no need to adjust his hypoglycemic agents urgently.
  • TPR, BP, SpO2 readings were relatively stable. No issue with active prescription. It might be necessary to follow up with an ECG and/or cardiac ultrasound on a regular basis.

2022-06-10

  • The patient was admitted to receive his scheduled FOLFOX regimen.
  • CEA and CA199 keep declining since April 2022.
  • Other lab results (2022-06-07) indicated that the readings were grossly normal.
  • No issue with active prescription.

2022-05-27

  • This is an economically disadvantaged patient who has been unemployed for many years and relies on relatives for financial support. He was diagnosed with stage IV A-colon cancer with mets in the first quarter of 2022, underwent right hemicolectomy in April of that year and was subsequently admitted to receive his first FOLFOX treatment.
  • TPR, BP, (2022-05-27) lab results (2022-05-26) were generally not bad. Self-carried items in active prescription are used to treat underlying health conditions.
  • The patient has a KRAS mutation (2022-04-29 detected) and may not benefit from anti-EGFR antibody treatment.
  • No issue with current medication.

700943429

220929

  • past history
    • The patient had cervical cancer stage I s/p for 6 years ago
    • history of operation: laparoscopic cervical resection and myoma resection for 6 years ago
    • Denied recent traveling history
    • Blood transfusion history: NIL
    • Regular medications or herb:no     
  • exam finding
    • 2022-06-24 Patho - stomach subtotal/tatal (tumor)
      • Diagnosis
        • Stomach, antrum, laparoscope radical subtotal gastectomy —- Poorly cohesive carcinoma, non-signet-ring cell type
        • Duodenum, laparoscope radical subtotal gastectomy —- Negative for malignancy
        • Margin: free
        • Lymph node, group 1, dissection —- Negative for malignancy (0/4)
        • Lymph node, group 3, dissection —- Metastatoc carcinoma (3/7)
        • Lymph node, group 4, dissection —- Negative for malignancy (0/9)
        • Lymph node, group 5, dissection —- Metastatic carcinoma (1/1)
        • Lymph node, group 6, dissection —- Negative for malignancy (0/13)
        • Lymph node, group 7, 8, 9, 11, 12, dissection —- Negative for malignancy (0/13)
        • Lymph node, group 14v, dissection —- Negative for malignancy (0/2)
        • AJCC 8 th edition p T N M Pathology stage: pStage IIIA, pT3N2(if cM0)
      • Gross Description:
        • Procedure: laparoscope radical subtotal gastectomy
        • Specimen size: Greater curvature: 11.5 cm, Lesser curvature: 8.5 cm, Duodenum: 0.5 cm
        • Tumor site: (check that apply): Antrum, lesser curvature
        • Tumor size: 2.0 x 1.5 cm
        • Gross configuration: Type III: Ulcerated with poorly defined infiltrative margins
        • Sections are taken and labeled as:
          • A1-2: proximal resection margin;
          • A3: distal resection margin;
          • A4: stomach, non-tumor;
          • A5-8: tumor;
          • B: lymph node, group 1;
          • C: lymph node, group 3;
          • D1-2: lymph node, group 4;
          • D3: omentum;
          • E: lymph node, group 5;
          • F: lymph node, group 6;
          • G1-2: lymph node, group 7, 8, 9, 11, 12;
          • H: lymph node, group 14v.
      • Microscopic Description:
        • Histologic Type: Lauren classification of adenocarcinoma: Diffuse type (WHO(2019) poorly cohesive carcinoma, non-signet-ring cell type); The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Negative (0)
        • Histologic Grade: G3: Poorly differentiated, undifferentiated
        • Tumor Extension: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
        • Margins
          • Proximal margin: uninvolved by invasive carcinoma: 2.9 cm
          • Distal margin: uninvolved by invasive carcinoma: 4.5 cm
          • Radial margin: uninvolved by invasive carcinoma: 0.2 cm
        • Lymphovascular Invasion: present
        • Perineural Invasion: present
        • Regional Lymph Nodes: please see diagnosis
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply): absent
          • Primary Tumor (pT): pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
          • Regional Lymph Nodes (pN): pN2: Metastasis in three to six regional lymph node
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
        • Additional Pathologic Findings
          • Intestinal metaplasia: present
          • Low-grade dysplasia: present
          • High-grade dysplasia: present
          • Helicobacter pylori-type gastritis: absent
          • Autoimmune atrophic chronic gastritis: absent
          • Polyp(s): absent
    • 2022-06-10 Doppler color flow mapping
      • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 17) / 80 = 78.75%
        • M-mode (Teichholz) = 77
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild MR, TR
    • 2022-05-27 CT - abdomen
      • History:
        • Epigastric fullness for days, Fasting epigastralgia
        • Belching and acid reflux, nausea(+), Decreased appetite(+), Weight loss(+)
        • 20220518 gastroscopy: A 2-3cm A2 ulcer was noted at angle, s/p biopsy, path:Intramucosal adenocarcinoma and gastric ulcer
      • Findings:
        • There is mild wall thickening at the gastric low body-antrum, measuring 0.9 cm in wall thickness.Please correlate with gastroscopy.
          • In addition, There is no enlarged node in the perigastric area.
        • There are several enhancing lesions in the uterus, the largestone measuring 5 cm in size, that may be myomas. Please correlate with GYN. sonography.
        • There is no focal lesion in both lung and mediastinum.
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T2 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:I(Stage_value)
    • 2022-05-18 Patho - stomach biopsy
      • PATHOLOGIC DIAGNOSIS
        • Stomach, angle, biopsy — Intramucosal adenocarcinoma and gastric ulcer
      • MACROSCOPIC EXAMINATION
        • The specimen submitted consists of multiple small pieces of gray-white soft tissue, labeled angle of stomach, measuring up to 0.4 x 0.2 x 0.2 cm. All for section.
      • MICROSCOPIC EXAMINATION
        • The sections show intramucosal adenocarcinoma, composed of gastric mucosal tissue with columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with focal stromal invasion. Gastric ulcer with necrosis and inflammatory exudate can be identified also.
    • 2022-05-18 SONO - abdomen
      • gallbladder polyp
    • 2021-12-22 Patho - colorectal polyp
      • Intestine, large, cecum, (A), biopsy removal — tubular adenoma
      • Intestine, large, transverse colon, (B), polypectomy —tubular adenoma
      • Intestine, large, transverse colon, (C), polypectomy —tubular adenoma
  • surgical operation
    • 2022-06-23
      • Surgery
        • laparoscope radical subtotal gastectomy with D2 LN dissection
      • Finding
        • 2 x 1.8 cm ulcerative mass at antrum lesser curvature
        • regional LN at LN 3, 5 & 8
  • chemoimmunotherapy
    • 2022-09-28 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
    • 2022-09-12 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
    • 2022-08-29 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
    • 2022-08-15 - oxaliplatin 70mg/m2 90mg 2hr + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr

700192852

220928

{Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.}

[objective]

  • lab data
    • CA125
      • 2022-07-19 CA-125 669.52 U/ml
      • 2022-06-13 CA-125 957.5 U/mL
      • 2022-06-10 CA-125 1194.15 U/ml
      • 2022-05-27 CA-125 1918.48 U/ml
      • 2022-04-22 CA-125 823.98 U/ml
      • 2022-02-11 CA-125 85.56 U/ml
      • 2020-12-29 CA-125 254.73 U/ml
      • 2020-12-11 CA-125 394.4 U/mL
      • 2018-09-08 CA 125 8.2 U/mL
    • CA199
      • 2022-07-19 CA-199 451.52 U/ml
      • 2022-06-10 CA-199 551.82 U/ml
      • 2022-05-27 CA-199 480.27 U/ml
      • 2022-02-09 CA-199 66.817 U/ml
      • 2020-12-29 CA-199 371.190 U/ml
      • 2020-12-11 CA-199 166.87 U/mL
      • 2018-09-10 CA-199 9.123 U/ml
  • exam finding
    • 2022-08-09 SmallIntestine
      • Segmental dilatation of proximal small bowel, suspected partial obstruction
    • 2022-07-11 Abdomen standing
      • S/P nasogastric tube insertion
      • Few segment of bowel in the middle abdomen show air-fluid level.
    • 2022-06-17 Small Intestinal Series
      • Dilated haustration of the jejunum and ileum and stomach as well as the doudenum is found.
      • The peristasis of the small intestine is retarded.
      • The transit time is 24 hours.
      • Imp: Paralytic ileus with delayed peristasis.
    • 2022-06-15 CT - abdomen, pelvis
      • Tumor seeding in the proximal jejunum induce bowel obstruction is highly suspected.
      • Carcinomatosis.
      • Metastatic nodes in the mesentery and para-aortic space.
      • Tumor seeding at the sigmoid colon and terminal ileum at the pelvis show stationary.
    • 2022-04-27 Small Intestine
      • Some indentation at bowel loop.
      • The passage time is about 4 hours.
    • 2022-04-25 CT - liver, spleen, biliary duct, pancreas
      • Suspected peritoneal seeding and liver/lung metastases.
      • Wall thickening of S-colon.
    • 2022-04-22 Patho - stomach biopsy
      • Stomach, pyloric ring, biopsy — ulcer with Helicobacter infection
    • 2022-04-22 Esophagogastroduodenoscopy
      • Diagnosis
        • Gastric ulcer, H2, pyloric ring, s/p biopsy
        • Suboptimal study due to much food residue in stomach and duodenum, probable due to bowel obstruction below 2nd portion
        • Reflux esophagitis LA Classification grade A
      • Suggestion
        • NG decompression
        • Small bowel series
    • 2022-04-15 KUB
      • Stool retention in the bowel.
    • 2022-04-01 KUB
      • Fecal material store in the colon.
    • 2022-01-21 Patho - soft tissue debridment
      • Ileum, exploratory laparotomy with segmental bowel resection with end to end anastomosis — benign perforated ileum with external tumor seeding and muscular invasion as well as necrotic acute inflammatory exudates containing tumor nests.
        • One of three peri-ileal lymph nodes (1/3) show tumor metastasis (2 x 1 mm).
        • IHC stains: CK20 (-): non-intestinal origin, PAX-8 (+), WT-1 (+), Napsin-A (-), p53 (aberrant type): compatible with serous carcinoma.
      • Labeled as ‘cut end 2’, exploratory laparotomy with segmental bowel resection with end to end anastomosis — Free.
      • Labeled as ‘cut end’, exploratory laparotomy with segmental bowel resection with end to end anastomosis — Free.
      • Labeled as ‘peritoneum tumor’, excision — serous carcinoma (4 x 3 mm).
        • IHC stains: CK20 (-), PAX-8 (+), WT-1 (+), Napsin-A (-), p53 (aberrant type).
    • 2022-01-20 CT - abdomen, pelvis
      • Pneumoperitoneum. Focal wall thickening of ileum suspected malignancy.
    • 2021-01-11 Pathology at VGHTPE
      • Recurrence from primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC, s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection)
      • PAX-8 (+), WT-1 (+), Napsin-A (-), p53 (aberrant type)
    • 2020-12-25 Small Intestinal Series
      • Normal haustration of the jejunum and ileum.
      • The peristasis of the small intestine is intact.
      • No evidence of stenotic or obstructive lesion in the study.
      • The transit time is 120 minutes.
      • Suggest clinical correlation
    • 2020-12-11 Gynecologic ultrasonography
      • Suspected Lt ovarian cyst
      • Uterine myoma
    • 2020-12-01 KUB
      • Stool retention in the bowel.
    • 2020-08-19 CT - abdomen, pelvis
      • Infectious colitis is suspected.
      • Please correlate with stool routine and culture, or colonoscopy.
    • 2019-04-01 SONO - breast
      • Right breast cyst and fibroadenoma. Suggest follow up.
      • BI-RADS2. benign finding
    • 2018-09-08 EKG
      • Sinus bradycardia with Premature atrial complexes
      • Prolonged QT
      • Abnormal ECG
    • 2018-09-08 SONO - breast
      • Suspected right breast tumor
      • Right fibroadenoma as described
      • Suggestion: tissue study
      • BI-RADS: suspicious abnormality, biopsy should be considered
    • 2018-09-08 Mammography
      • Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative.-annual screening.
    • 2018-09-08 Low-dose CT - lung cancer screening
      • Lungs: Nodular lesion at left upper lobe up to 4.7mm in largest dimension.
  • consultation
    • 2022-06-15 General and Gastrointestinal Surgery
      • A
        • She suffered from had acute abdomen pain with fever due to ca involved small bowel with perforation and adhesions status post op 4 months ago
        • P.E showed soft abdomen, no muscle guarding, no local tendderness but severe abdomen distention
        • tumor markers and image studies in favor of cancer metastasis
        • Further C/T or immonotherapy is idicated
        • Give PN if oral feeding can not proceed
    • 2022-02-09 thoracic surgery
      • Q
        • This 60 year-old female had past history of 1) Myomectomy 20 years ago. 2) Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC, s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111. This time, she suffered from abdomen pain since 20220120 morning. She was brought to our ER, her consciousness remained E4V5M6. KUB showed calcification in LUQ, suspected left renal stone. Abdomen CT revealed pneumoperitoneum due to hollow organ perforation and carcinomatosis. After GS was consulted and suggested emergency survey was indicated. She underwent Exp. lap. with primary repair, lysis of adhesions, segmental bowel resection with end to end anastomosis excision of peritoneal tumor and multiple drainage on 20220120.
        • We need your expertise in evaluation and performing CVC insertion to facilitate TPN infusion in the immediate future.
      • A
        • I will arrange central venous catheterization. Thanks for your consultation.
    • 2022-01-20 gastroenterological surgery
      • Q
        • abdomenial pain VAS 4-7, no fever, nausea +, no diarrhea, deny tarry or bloody stool
        • PH: peritoneal cancer s/p op in Jan 2021 at Taipei Veterans General Hospital
        • allergy: aspirin
        • s/p 2 doses of covid vaccine
      • A
        • Acute left abdominal pain with fever with chillness for days
        • P.E showed diffuse local tenderness with muscle guarding esp left abdomen
        • Lab and CT in favor of pneumoperitoneum due to hollow organ perforation and carcinomatosis
        • Emergency op is indicated
  • past history
    • Myomectomy 20 years ago.
    • Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.
  • surgical operation
    • 2022-01-20
      • Surgery
        • Exp. lap. with primary repair,lysis of adhesions,segmental bowel resection with end to end anastomosis excision of peritoneal tumor and multiple drainage.
      • Finding
        • Bowel perforation of upper jejunum, 1.5cm in diameter, cause?
        • Severe adhesions and desmoplastic reaction over lower abdomen with focal or segmental bowel ischemic chnage and serosal tear
        • Multiple small nodules ove peritoneum and mesencary
        • A lot of turbid fluid over intraabdominal spaces, 100ml in amount
  • chemoimmunotherapy
    • 2022-09-09 - pembrolizumab 200mg 1.5hr
    • 2022-08-23 - liposome doxorubicin 40mg/m2 50mg 2hr
    • 2022-08-16 - pembrolizumab 200mg 1.5hr
    • 2022-07-26 - pembrolizumab 200mg 1.5hr + liposome doxorubicin 40mg/m2 57mg 2hr
    • 2022-07-05 - pembrolizumab 200mg 1.5hr
    • 2022-06-28 - liposome doxorubicin 40mg/m2 50mg 2hr
    • 2022-06-15 - pembrolizumab 200mg 1.5hr
    • 2022-05-30 - liposome doxorubicin 40mg/m2 57mg 2hr
    • 2022-05-24 - pembrolizumab 200mg 1.5hr
    • 2022-05-03 - pembrolizumab 200mg 1.5hr + liposome doxorubicin 40mg/m2 57mg 2hr

==========

2022-06-27

  • Hyperphosphatemia (7.5mg/dL 2022-06-26) might possibly due to tumor lysis syndrome?
  • The hyperphosphatemia usually resolves within 6 to 12 hours if kidney function is intact. If kidney function is intact (creatinine 0.48 mg/dL, BUN 12 mg/dL 2022-06-26), phosphate excretion can be increased by saline infusion, although this can further reduce the serum calcium concentration by dilution.

2022-04-25

  • Lab data on 2022-04-21, liver and kidney functions, serum electrolytes and blood cell counts were grossly normal, however the ca125 level of 823 U/mL was a record high.
  • The use of a platinum based regimen, specifically paclitaxel/carboplatin Q3W, is recommended for serous carcinoma of either low grade or high grade. The addition of bevacizumab can also be considered.
  • Acid reflux remains an active issue since 2022-04-22. Some H2 antagonists or PPIs may provide some relief. The prescription for pantoprazole 40mg IVD QD has been made.
  • This patient is allergic to aspirin, which is not currently prescribed.

700695787

220927

  • past history
    • Hypertension
    • Hyperlipidemia
    • Type II Diabetes Mellitus
    • Chronic kidney disease, stage III
    • Benign Prostatic Hyperplasia
  • exam finding
    • 2022-09-26 CXR
      • Ground glass opacity in bilateral lower lungs.
      • Cardiomegaly.
      • Atherosclerosis of the aorta.
    • 2022-09-26 CT - abdomen
      • Splenomegaly with some low attenuations suspected infarcts.
      • Partial consolidation at LLL. Left pleural effusion.
      • Mild distention of left renal pelvis.
      • Some LNs (up to 1.1cm) at retroperitoneum.
      • Gallbladder stone (0.7cm).
      • Cardiomegaly.
    • 2022-06-20 SONO - nephrology
      • Left hydronephrosis
      • Left renal stone
      • Bilateral renal cysts
    • 2022-05-09 Effective renal plasma flow, ERPF
      • The ERPF values of the right kidney and the left kidney are 154.5 ml/min and 79.1 ml/min, respectively (normal reference range of ERPF: > 150 ml/min in each kidney for adults). There is decreased renal plasma flow to the left kidney.
      • Delayed radiotracer washout from the right kidney is noted, indicating obstructive uropathy in the right kidney.
      • It is indeterminate for obstructive uropathy of the left kidney because of diminished left renal function. Please correlate with other clinical findings for further evaluation.
    • 2022-04-27 Intravenous pyelogram, IVP
      • No evidence of urolithiasis.
    • 2022-03-28 SONO - nephrology
      • Parenchymal renal disease with enlarged parenchyma, bilateral, suspect diabetic nephropathy
      • Hydronephrosis, left
      • Simple cyst, bilateral
    • 2021-10-18 ECG
      • Sinus rhythm with 1st degree A-V block
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG

[assessment]

  • Currently, there are antiglycemic agents (Januvia, sitagliptin 100mg, PO QD; Loditon, metformin 850mg, PO BID) on the active prescription list. On 2022-09-26, a blood glucose level of 300mg/dL was recorded prior to dinner. The use of Dibose (acarbose 100mg/tab, available in stock) 1# TID might be initialized if two or more consecutive data points exceed 200mg/dL.

700811991

220927

  • lab data
    • 2022-09-09 Anti-HBc Reactive
    • 2022-09-09 Anti-HBc-Value 4.74 S/CO
    • 2022-09-09 Anti-HBs 8.30 mIU/mL
    • 2022-08-25 HBsAg Negative
    • 2022-08-25 HBsAg Value 0.538
    • 2022-08-25 Anti-HCV Negative
    • 2022-08-25 Anti-HCV Value 0.0352
  • exam finding
    • 2022-09-16 CXR
      • Multiple nodules at bil. lungs.
    • 2022-08-30 All-RAS + BRAF mutations assay
      • All-RAS mutations assay
        • Detection range
          • KRAS codon 12, 13, 59, 61, 117, 146
          • NRAS codon 12, 13, 59, 61, 117, 146
        • Results
          • Detected (KRAS codon 12 GGT>GTT, p.G12V)
        • Interpretation
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
      • BRAF mutations assay
        • Detection range
          • BRAF codon 600
        • Results
          • There was no variant detected in the BRAF gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • 2022-08-28 Standing KUB
      • Degeneration and spondylosis of L-S spine.
    • 2022-08-25 Patho - colon segmental resection for tumor
      • Diagnosis:
        • Intestine, large, sigmoid colon, left hemicolectomy — Moderately differentiated adenocarcinoma
        • Proximal anastomosis: Negative for malignancy
        • Distal anastomosis: Negative for malignancy
        • Lymph node, regiona, dissection — Metastatic adenocarcinoma (4/18)
        • AJCC 8th edition pathology stage: T3N2a( cM1); AJCC stage IVA, at least
      • Gross Description:
        • Procedure: Left hemicolectomy
        • Tumor Site: Sigmoid colon
        • Tumor Size: 4.8x 3.5 cm.
        • Macroscopic Tumor Perforation: Not identified
      • Microscopic Description:
        • Histologic Type: Adenocarcinoma
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
        • Margins:
          • Proximal margin: Uninvolved
          • Distal margin: Uninvolved
          • Radial or Mesenteric Margin: Involved
          • Lymphovascular Invasion: Present
          • Perineural Invasion: Not identified
          • Tumor Budding:
            • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
            • Intermediate score (5-9)
        • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
        • Tumor Deposits: Not identified
          • Specify number of deposits: N/A
        • Regional Lymph Nodes
          • Number of Lymph Nodes Involved/Examined: 4 / 18, with extranodal extension
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition):
          • TNM Descriptors (required only if applicable) (select all that apply)
            • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT):
            • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN):
            • pN2a: Four to six regional lymph nodes are positive
          • Distant Metastasis (pM):
            • N/A
    • 2022-08-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 33) / 108 = 69.44%
        • M-mode (Teichholz) = 69
      • Normal LV systolic function with normal wall motion.
      • LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Mild MR; mild TR; aortic valve sclerosis.
    • 2022-08-23 Flow Volume Curve
      • Mild obstructive pulmonary function impairment
    • 2022-08-22 CXR
      • Multiple nodules at bil. lungs.
    • 2022-08-22 CT - abdomen
      • History
        • 73 y/o 2022-07-17 abdominal pain off and on for a period of time
        • PI : diarrhea (-) constipation (-) BW loss (-) appetite : good, relieving factor (-)
        • PHx : HTN (+) DM (+) Op. (+) prostate hypertrophy CAD s/p stenting
      • Imp
        • Suspected colon cancer at rectosigmoid colon with lung meta and regional lymph nodes
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value)
    • 2022-08-11 Patho - colon biopsy
      • R-S junction, 20 cm AAV, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular, cribriform, and papillary patterns with desmoplastic stromal reaction.
      • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2022-08-10 Colonoscopy
      • Suspected colon cancer, 20cm AAV, s/p biopsy
      • Internal hemorrhoid
  • chemoimmunotherapy
    • 2022-09-26 - irinotecan 120mg/m2 150mg 90min + leuocovrin 300mg/m2 450mg 2hr + fluorouracil 2400mg/m2 3700mg 46hr

[assessment]

  • Pathology performed in late August 2022 revealed the disease to be characterized by pMMR, EGFR(+), KRAS codon 12 mutations, without BRAF mutations.
    • pMMR => it would be less prominent in the effect of pembrolizumab or nivolumab +- ipilimumab.
    • mutated RAS => the effect of anti-EGFR antibody treatment (e.g., panitumumab, cetuximab) might be mitigated.
    • lack of BRAF codon 600 mutatation => encorafenib might not be the choice.
  • The blood pressure appears to be under control (with bisoprolol and nicorandil); however, the blood sugar appears to be a little higher (with metformin and vildagliptin). The addition of a hypoglycemic agent is not urgently required yet.

700155901

220926

  • exam finding
    • 2022-09-13, -09-06, 09-02, 08-24, 08-19, 08-10, 08-05 CXR
      • Blunting of bilateral costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Atherosclerotic change of aortic arch
    • 2022-08-05, -07-11 Abdomen - standing (diaphragm)
      • Increase soft tissue density of the right lower abdomen is noted that is c/w local recurrent tumor after correlate with prior CT on 20220625.
      • Spondylosis with scoliosis of the L-spine with convex to left side
    • 2022-07-14 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 23) / 93 = 75.27%
        • M-mode (Teichholz) = 75
      • Dilated LA
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild PR, TR
    • 2022-07-11 KUB
      • Increase soft tissue density of the RLQ abdomen is suspected. Please correlate with CT for further evaluation.
      • Ascites is suspected.
    • 2022-07-11 Patho - uterus with or without SO
      • DIAGNOSIS: Tissue, pelvic, biopsy — malignant tumor, high-grade
      • Microscopically, it shows mlaignant tumor composed of high-grade tumor cells arranged in solid architacture and focal glandular differentiation. The tumor shows nuclear hyperchromasia, pleomorphism, and mitotic activity.
      • Immunohistochemical stain reveals CK (focal +), PXA-8(+), WT-1(-), CK20(-).
    • 2022-07-05 Gynecologic ultrasonography
      • Suspected pelvis mass: (1) 197x122mm (2) 64x41mm
      • Ascites (+)
    • 2022-06-25 CT - abodmen
      • S/P hysterectomy with minimal ascites. Some recurrent tumors (up to 13.3cm) in peritoneal cavity.
    • 2022-02-18 SONO - abdomen
      • Two hepatic cysts in S6/7 and S5 are suspected. Follow up is indicated.
      • S/P cholecystectomy.
    • 2022-02-04 CT - abdomen
      • History:
        • Endometrial carcinosarcoma S/P hysterectomy and adjuvant chemo and radiotherapy
      • Impression
        • There are two poor enhancing lesion measuring 0.4 cm in S6/7 and 0.6 cm in S5 and of the liver that may be metastases or cysts? Please correlate with sonography and MRI.
    • 2021-10-15 MRI - pelvis
      • S/P hysterectomy and oophorectomy. Suggest follow up.
      • Suspected R/O left renal cyst.
    • 2021-09-02 Pure tone audiometry, PTA
      • Reliability FAIR
      • Average RE 28 dB HL / LE 30 dB HL
      • bil normal to moderate SNHL
    • 2021-07-22 Gynecologic ultrasonography
      • ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2021-07-12 Patho - uterus with or without SO
      • PATHOLOGIC DIAGNOSIS
        • Uterus, endometrium, staging surgery — carcinosarcoma, poorly differentiated
        • Uterus, myometrium, staging surgery — Involved by carcinosarcoma (< 1/2 thickness) — intramural myomas
        • Uterus, cervix, staging surgery — endocervical polyp
        • Ovary and fallopian tubes, right, staging surgery — Involved by carcinosarcoma
        • Ovary and fallopian tubes, left, staging surgery — Negative for malignancy
        • Lymph node, left iliac, dissection — Negative for malignancy (0/2)
        • Lymph node, left obturator, dissection — Negative for malignancy (0/4)
        • Lymph node, right iliac, dissection — Negative for malignancy (0/2)
        • Lymph node, right obturator, dissection — Negative for malignancy (0/5)
        • Lymph node, left paraaortic, dissection — Negative for malignancy (0/1)
        • Lymph node, right paraaortic, dissection — Negative for malignancy (0/3)
        • Omentum, omentectomy— Positive for carcinosarcoma
        • AJCC 8th edition Pathology stage: pT3aN0M1; FIGO IVB, AJCC stage IVB
        • Additional Pathologic Findings — Carcinosarcoma with heterologous rhabdomyosarcomatous differentiation (S2021-08805)
        • Ancillary Studies: IHC stain — vimentin( +), ER(-), PR:+(moderate, 60%), CK(+), SMA (-)
    • 2021-07-06 MRI - pelvis
      • Imaging Report Form for Endometrial Carcinoma
        • Impression (Imaging stage) : T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:Ia(Stage_value)
      • Impression:
        • Prominent soft tissue in the uterine cavity, suspected endometrial malignancy, if proven malignancy, cstage T1aN0M0.
        • Utereine myoma.
        • Enhancing lesion in right ischial bone, suggest bone scan correlation.
    • 2021-07-06 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, endometrial curettage — Carcinosarcoma with heterologous rhabdomyosarcomatous differentiation
      • IHC: CK(+ for epithelial component), Vimentin(+ for sarcomatous component), Desmin(+ for rhabdomyoblasts), and Myogenin(+ for rhabdomyoblasts).
    • 2021-07-05 Gynecologic ultrasonography
      • bilateral adnexae: free
      • endometrial hyperplasia: 51.4mm (RI: 0.24)
    • 2021-03-13 SONO - nephrology
      • a 0.61cm hyperecholic lesion without acoustic shadow in the cortex of middle portion, left kidney, suspect hypercalcification lesion
      • Interpretation: Bilateral parenchymal renal disease
      • A calcification lesion, left kidney
    • 2020-05-07 SONO - nephrology
      • Left renal stones.
      • Parenchymal renal disease.
    • 2019-08-22 SONO - abdomen
      • Mild fatty liver. S/P cholecystectomy. Suspected left renal angiomyolipoma

[assessment]

  • The blood pressure and blood sugar levels are within the normal range.

  • Human albumin 20g QD, furosemide 20mg QD, and spironolactone 25mg BID are currently being used to control patient edema.

  • Blood pressure and blood sugar are grossly in normal range.

  • Human albumin 20g QD, furosemide 20mg QD, spironolactone 25mg BID are currently applied to cope with the patients edema.

700316910

220926

  • exam finding
    • 2022-09-25 CT - abdomen
      • Rectal cancer s/p operation.
      • Bony metastases at sacrum and pelvic bones with adjacent tructures invason causing left hydronephrosis/hydroureter. Multiple LNs, liver and lung metastases. General subcutaneous edema.
    • 2022-09-25 KUB
      • Bony destruction of sacrum and pelvic bones.
      • Presence of ileus.
    • 2022-09-25 CXR
      • Multiple nodules at bil. lungs.
    • 2022-07-14 CXR
      • Patch density at right lower lung zone.
    • 2022-07-14 KUB
      • Degeneration of bony structures.
      • Some lucent lesions in bony structures.
      • Deformity of right pubic bone.
      • Stool retention in bowl.
    • 2022-07-14 ECG
      • Normal sinus rhythm
      • T wave abnormality, consider inferolateral ischemia
      • Abnormal ECG
    • 2021-12-10 Peripheral Vascular Test - vein, lower limbs
      • Clinical diagnosis: left leg edema, pelvic cancer
      • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
        • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
        • Spontaneous signal N N N N N N N N N N
        • Respiratory changes N N N N N A A A A A
        • Cough response N N N N N N N N N N
        • Compression study N N N N N N N N N N
        • Right Left N N N N N N N N N N
      • Report:
        • Thrombus : None
        • Varicose vein : None
      • Right side:
        • SVC: 11.3 mmHg ; 12.7 mmHg ;
        • MVO/SVC: 89 % ; 83 % ;
        • Average MVO/SVC: 86 %
      • Left side:
        • SVC: 8.0 mmHg ; 10.3 mmHg ;
        • MVO/SVC: 75 % ; 66 % ;
        • Average MVO/SVC: 70 %
      • Conclusion:
        • There was no evidence of DVT detecetd at both lower limbs venous system.
        • Loss of respiratory change of venous flow at left CFA, PFA, SFA and popliteal vein, consider left iliofemoral venous stenosis or obstruction. A large perforator vein anastomosed the left PTV and left LSV at left lower calf level was detected.
        • Bilateral saphenofemoral venous junction (LSV) and saphenopopliteal venous junction (SSV) were competent without venous reflux.
        • The measured MVO/SVC at right thigh was normal (86%). However, the measured MVO/SVC ratio at left thigh was 70%, compatible with left iliofemoral venous stenosis or obstruction.
    • 2021-11-15 MRI - L-spine
      • Findings
        • Large area of Bone destructions at S1-2-3, mainly at left, with neuroformen impingement.
        • No evident bony destructive lesion at T-spine.
        • Normal cord size and signal intensity.
      • Impression
        • Favor large area of sacral bone metastases.
    • 2021-11-15 CT - abdomen
      • Rectal cancer s/p operation. Bony metastases at sacrum with adjacent tructures invason causing left hydronephrosis/hydroureter. Multiple lung metastases.
    • 2021-11-15 KUB + L-spine Lat
      • increased air in nondistended loops of small bowel over abdomen and pelvic
      • large osteolytic change at sacrum especially left side due to metastasis, in progression as compared with previous images on 20210714.
    • 2021-03-02 CT - abdomen
      • Post-op at the colon.
      • Destructive lesion in the sacrum, suspected metastasis.
      • RLL nodule, suspected lung metastasis.
      • Gallbladder stones.
      • Suspected liver cysts.
    • 2021-01-05 CT - abdomen
      • Recurrent colon cancer at sacrum. Suggest further treatment.
    • 2020-10-13 CT - abdomen
      • No evidence of recurrent tumor in the study.
    • 2020-08-20 Tc-99m MDP whole body bone scan with SPECT
      • Increased activity in the sacrum and adjacent left S-I joint. Bone metastasis should be considered. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular juntions and knees, compatible with benign joint lesions.
    • 2020-08-18
      • Subtle osteolytic lesion in the left side 1st and 2nd sacrum is noted that is compatible with bony metastasis after correlate with prior CT on 2020-04-28 and MRI on 2020-07-17 from TSGH. Please correlate with clinical condition.
    • 2020-07-21 CT - chest
      • a tiny RUL-S3 perifussural nodule, stationary, favor an intrapulmonary LN. no mediastinal tumor.
    • 2020-04-28 CT - abdomen
      • Post-op at the colon. Suggest follow up.
      • GB stones.
      • Liver cysts.
    • 2020-02-04 SONO - abdomen
      • Mild fatty liver.
      • There are several hepatic cysts in both lobes and the largest one is measured about 1.7 cm in size at S6.
      • A gallstone measuring 0.64 cm.
    • 2019-10-29 CT - abdomen
      • Clinical history:
        • 57 y/o male patient with rectal CA, ypT3N1b (3/12) cM0, stage IIIB Dx in July 2017 at ShuangHo Hospital s/p CCRT at ShuangHo Hospital & s/p Op in Oct 2017 by Dr Xiao GuangHong, s/p post-Op adjuvant Oxaliplatin (self-paid) / HDFL IV Q2W x 12 finishing in May 2018, Rectum, laparoscopic LAR (20171025): AdenoCA, MD, LNs, mesorectal, dissection: Metastatic adenocarcinoma (3/12) Pathology stage: ypT3N1b(cM0), stage IIIB.
        • Rectal cancer, cT3N1M0; stage III s/p CCRT at 10 cm from AV at ShuangHo Hospital
      • Impression
        • Post-op at the colon. suggest follow up.
        • Liver cysts.
        • GB stone.
    • 2019-08-08 CT - chest
      • Pleura traction at right upper lobe, right upper lobe nodule. These two findigs are stationary.
    • 2019-07-30 SONO - abdomen
      • Mild fatty liver.
      • There are several hepatic cysts in both lobes and the largest one is measured about 1.7 cm in size at S6.
      • A gallstone measuring 0.86 cm and a polyp 0.21 cm.
    • 2019-05-07 CT - abdomen
      • No evidence of recurrent tumor in the study.
      • Cystic duct stone.
    • 2019-02-12 CT - chest
      • The peripheral tiny nodule at RUL is pleural fat protrudining and indenting the lung.
      • no interval change of a tiny nodule (about 2mm) at RUL.
    • 2018-08-14 SONO - hepatobiliary
      • Small hepatic cysts, up to 1.28 cm. A gallstone.
    • 2018-05-29 CT - chest
      • Tiny nodules (2.2mm, 3.6mm) at RUL.
    • 2018-05-24 CT - abdomen
      • S/P operation.
      • Liver cysts (0.5-1.6cm).
      • Gall stone (6mm).
    • 2017-10-26 Surgical pathology Level VI
      • PATHOLOGIC DIAGNOSIS
        • Rectum, laparoscopic LAR — Adenocarcinoma, moderately differentiated
        • Resection margins: Free
        • Lymph nodes, mesorectal, dissection — Metastatic adenocarcinoma (3/12)
        • Pathology stage: ypT3N1b(cM0), stage IIIB
      • MICROSCOPIC EXAMINATION
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: To perirectal soft tissue
        • Angiolymphatic invasion: Not identified
        • Perineural invasion: Not identified
        • Discontinuous extramural tumor extension: Not identified
        • Circumferential (radial) margin of rectum: Uninvolved, 10 mm from the margin
        • Lymph node metastasis, mesorectal: Metastatic adenocarcinoma (3/12)
        • Extranodal involvement: Not identified
        • Pathological TNM Stage: ypT3N1b(cMx)
        • Type of polyp in which invasive carcinoma arose: Not identified
        • Additional pathologic findings: None identified
        • TNM descriptors: y (Post-treatment)
        • Tumor regression grading S/P CCRT: Grade 2 (partial response)
        • Proximal and distal margins: Free of tumor
        • IHC for mismatch repair proteins:
          • MSH6: Intack nuclear expression
          • PMS2: Intack nuclear expression
  • surgical operation
    • 2021-12-28 bil. lumbar sympathetic block
      • pain management procedural note
        • The patient lay prone on a radiolucent table with a pillow under the upper abdomen.
        • The site of vertebral bodies were marked out with the X-ray beam in the postero-anterior axis.
        • The double end-plate at border of L2 vertebral body was corrected by angling the intensifier.
        • The X-ray beam was gently rotated obliquely away from the spine, until the edge of the transverse process along the border of vertebral body.
        • A mark was made.
        • After local anesthetic infiltration, a 22G, 150 mm long needle was inserted along the X-ray beam.
        • The angle of the needle was adjusted to obtain tunnel view, and the needle was poised to contact the anteriolateral border of the vertebral body.
        • Contrast medium was injected to assure the proper needle tip position in both P-A and lateral X-ray views.
        • Then 5 ml of 0.5% buivacaine  was injected.
        • The other targeted sites were proceeded in the same manner.
        • complication nil    
        • blood loss <1ml 
    • 2018-06-06 Closure of enterostomy or Colostomy (loop or double-barrel)
      • PCS code: 73020C
      • Finding
        • Loop ileostomy at Right abdomen
    • 2017-10-25 Restorative proctectomy with colo-analanastomosis
      • PCS code: 74213B
      • Finding
        • Rectal cancer s/p CCRT with tumor shrinkage remaining a scar at 6 cm from AV
        • Narrow pelvis
  • chemoimmunotherapy
    • 2021-05-31 - bevacizumab 5mg/kg 400mg 1.5hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr
    • 2021-03-16 - irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

[assessment]

  • The addition of a PPI might be beneficial in the event of stool OB 4+ (2022-09-25) and suspicion of GI bleeding.
  • A temporary hold on NSAIDs (diclofenac, patient-carried) may also be an option in this situation.
  • Diclofenac adverse reactions and incidences - Gastrointestinal: nausea (3% to 14%), abdominal pain (4% to 7%), constipation (8%), diarrhea (6%), duodenal ulcer, dyspepsia (2%), flatulence (2% to 3%), gastric ulcer, gastrointestinal hemorrhage, gastrointestinal perforation, heartburn, upper abdominal pain (3%), vomiting (3% to 6%).

700377487

220926

{multiple myeloma}

  • exam finding
    • 2022-09-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 32) / 80 = 60%
      • Normal LV systolic function with abnormal septal wall motion due to RV pressure overload.
      • Hypertrophic cardiomyopathy without outflow tract obstruction, dilated LA; LV diastolic dysfunction Gr 3 (restrive pattern).
      • Dilated RA and RV; Impaired RV systolic function with free wall hypokinesia.
      • Mild to moderate MR; moderate to severe TR.
      • Possible moderate pulmonary hypertension, estimated PASP: 40 mmHg (systemic systolic pressure: 95mmHg).
      • Engorgement of IVC with poor inspiratory collapse, consider fluid overload.
      • Dilated aortic root and ascending aorta.
      • Minimal pericardial effusion.
    • 2022-09-22 CXR
      • Ground glass opacity in RLL.
      • Normal appearance of trachea and bil. main bronchus.
      • Cardiomegaly.
      • Widening of mediastinum.
    • 2022-09-15 L-spine 4 views (including sacrum)
      • mild spondylolisthesis at L4-5
      • Unremarkable change in the width of the bony spinal canal
      • mild anterior spur formation at the L-spine
      • moderate decreased disc space in the L4/5 disc
      • Unremarkable change in the paravertebral region
      • compression fractures at L1, T12 and T11 vertebral bodies
    • 2022-08-18 Uroflow
      • Q max: fair
      • flow pattern: normal
    • 2022-08-18 Bladder Sosography
      • PVR: 11.35mL (postvoided residual)
    • 2022-07-21 Transrectal Ultrasound of Prostate, TRUS-P
      • Findings
        • Prostate
          • Size of prostate: 3(T)cm x 4.6(L)cm x 4.6(AP)cm = 34cc
          • Size of adenoma: 2(T)cm x 2.4(L)cm x 3.4(AP)cm = 0.9cc
      • Seminal vesicles:
        • L
          • Size:L’t1.7 x 0.6 cm
          • Vas deferens:Normal
          • Cyst:No
          • Abscess:No
          • Tumor:No
        • R
          • Size:R’t1.5 x 0.4 cm
          • Vas deferens:Normal
          • Cyst:No
          • Abscess:No
          • Tumor:No
      • Diagnosis
        • Benign prostatic hyperplasia
    • 2022-06-30 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
      • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • 2022-06-18 SONO - Nephrology
      • Chronic parenchymal renal disease.
      • Right renal cysts, cortical and parap
    • 2022-06-17 SONO - abdomen
      • Parenchymal liver disease
      • Gallbladder stones
      • Cholecystopathy
      • Bilateral renal cysts
      • Splenomegaly
      • Splenic hyperechoic lesion, nature? suspected hemangioma
      • Minimal ascites
      • Bilateral pleural effusion
    • 2022-06-15 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 21) / 91 = 76.92%
        • M-mode (Teichholz) 77
      • Dilated LA,Ao,RA,RV,PA,IVC
      • Biventricular hypertrophy
      • Poor RV systolic function
      • Adequate LV systolic function, abnormal septal wall motion due to RV failure
      • Impaired LV relaxation
      • Moderate MR,PR
      • Severe TR
      • Minimal amount pericardial effusion, No tamponade, No pericardial constriction at present
      • Paroxysmal atrial fibrillation or MAT rhythm
    • 2022-06-14 ECG
      • Atrial fibrillation with rapid ventricular response
      • Left axis deviation
      • Anterior infarct, age undetermined
      • Abnormal ECG
    • 2022-05-06 Ultrasound of male genital organs
      • Scrotal soft tissue edema
      • Enlarged Right epididymis without vascularity, epididymitis was not likely
    • 2022-05-01 KUB
      • Blunted right costophrenic angle.
      • Degeneration and spondylosis of L-S spine.
    • 2022-05-01 ECG
      • Sinus tachycardia
      • Left axis deviation
      • Anteroseptal infarct, age undetermined
    • 2022-02-14 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 35) / 111 = 68.47%
        • M-mode (Teichholz) 68
      • Adequate LV systolic function with normal resting wall motion
      • Moderate MR, moderate TR and trivial PR
      • Dilated LA, septal hypertrophy
      • Preserved RV systolic function
      • Dilated aortic root
    • 2022-02-14 SONO - chest
      • Bilateral trivial pleural effusion (right > left).
    • 2022-02-10 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2022-02-09 MRI - retroperitoneum
      • History: both lower legs edema Suspected Retroperitoneum lesion?
      • Past Hx: multiple myeloma
      • Findings
        • There is a newly-developed soft tissue mass measuring 3.8 x 2.5 cm in the lower pole of spleen with exophytic growth, showing hypointensity on T1WI, mild hyperintensity on both T2WI and DWI. However, there is no signal drop on ADC.
          • Please correlate with contrast enhanced dynamic MRI to R/O extramedullary plasmacytoma or angiosarcoma.
        • There is no retroperitoneal lesion and no extrinsic compression lesion in the IVC, bilateral iliac vein, and bilateral femoral vein.
          • The IVC, iliac vein, and femoral vein show no filling defect.
        • There is periportal lucency and gallbladder wall edema that may be hypoalbuminemia.
          • In addition, There is edematous change in the subcutaneous fat layer of anterior abdominal wall, bilateral flank area and pre-sacral space that also may be due to hypoalbuminemia. please correlate with clinical condition.
        • There is mild ascites in perihepatic and perisplenic space.
        • Mild bilateral Pleura effusion are noted.
        • There is a diverticulum measuring 2.6 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at right upper pole.
        • There are few gallstones and the size < 1.5 cm.
        • There is no focal abnormality in the biliary system and pancreas.
        • There is no evidence of lymphadenopathy.
        • The abdominal aorta and IVC are grossly unremarkable.
      • IMP:
        • Splenic mass,nature? Please correlate with contrast enhanced dynamic MRI to R/O extramedullary plasmacytoma or angiosarcoma.
        • There is no retroperitoneal lesion and no extrinsic compression lesion in the IVC, bilateral iliac vein, and bilateral femoral vein. The IVC, iliac vein, and femoral vein show no filling defect.
    • 2022-01-26 Peripheral Vascular Test - vein, lower limbs
      • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
        • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
        • Spontaneous signal N N N N A N N N N A
        • Respiratory changes N N N N N N N N N N
        • Cough response N N N N N N N N N N
        • Compression study N N N N N N N N N N
        • Right Left N N N N N N N N N N
      • Report:
        • Right side:
          • SVC: 11.8 mmHg ; 14.2 mmHg ;
          • MVO/SVC: 90 % ; 86 % ;
          • Average MVO/SVC: 88 %
        • Left side:
          • SVC: 8.6 mmHg ; 10.9 mmHg ;
          • MVO/SVC: 100 % ; 91 % ;
          • Average MVO/SVC: 95 %
      • Conclusion:
        • No venous thormbosis at bilateral deep and superficial venous system
        • No varicose vein at both GSV/SSV with mild venous reflux reponse with sponteanous reversal flow
        • Marked interstititla edema at both calf site, plese correlate with serum albumin level or renal function
        • The MVO/SVC ratio showed no significant venous obstruction at iliac iven or IVC level
    • 2022-01-25, -01-24 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2022-01-24 ECG
      • Left axis deviation
      • Anteroseptal infarct , age undetermined
      • Prolonged QT
      • Non-specific intra-ventricular conduction delay
    • 2021-10-07 Patho - bone marrow biopsy
      • Clinical finding: R/I MM recurrence
      • Ciinical diagnosis: C90.00 Multiple myeloma not having achieved remission
      • DIAGNOSIS: Bone marrow, rigth ileum, biopsy — Multiple myeloma
      • Microscopically, it shows 90% cellularity of bone marrow with diffuse proliferation of plasma cells admixed with some myeloid and erythroid cells and occsaional megakaryocytes. No blast is seen. It is compatible with multiple myeloma.
      • Immunohistochemical stain reveals CD138(diffuse +), MPO(foal+), CD71(focal+), Kappa chain (-), lambda chain (+), CD34(-), CD117(-), TdT(-),and CD20(-).
    • 2021-08-16 SONO - nephrology
      • slightly enlargement of both kidneys
      • right renal cysts
      • gall stones? > 3 stones
      • spleen tumor?
    • 2021-07-23 Myocardial perfusion SPECT with persantin
      • Probably mild myocardial ischemia at the apex.
      • Reverse redistribution of radioactivity to the basal lateral wall, either normal variant or myocardial ischemia may show this picture.
    • 2021-07-21 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (98.3 - 35.3) / 98.3 = 64.09%
        • M-mode (Teichholz) 64.1
      • Dilated aortic root
      • Thickening of IVS
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Mild MR, AR, TR and PR
      • No regional wall motion abnormalities
    • 2021-07-19 ECG
      • Normal sinus rhythm
      • Left anterior fascicular block
      • Septal infarct, age undetermined
      • Abnormal ECG
    • 2018-12-13 Surgical pathology Level IV
      • Clinical diagnosis
        • Multiple myeloma, without mention of remission; Anemia, unspecified.
      • Diagnosis
        • Bone marrow, side? biopsy — Multiple myeloma
      • Sections show 80-100 % cellularity. There are diffuse interstitial infiltrates and aggregates with immature plasma cells. The plasma cells accounts for about 80-100% of all nucleated cells. Megakaryocytes are found about 0-5/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
      • Immunohistochemical stains reveal CD138(+), CD20(-), Kappa light chain(-), and Lambda light chain (+). The Ki-67 is < 1%.
  • consultation
    • 2022-06-15 Cardiology
      • Q
        • for heart failure & dyspnea
        • This 64-yera-old man, a patient of multiple myeloma S/P C/T. He was admitted due to dyspnea & heart failure and acute hepatitis. Fever 37.9 degree C without chills was noted at home.
        • pt is taking Houttuynia cordata for 2 days and both lower legs edema and laboratory showed NT-pro BNP: > 25000, hs-Troponin I:1571, CK-MB:128. We need expertise to evaluate his condition thanks!
      • A
        • This is a 64 years old man who has HBV carrier under entecavir, multiple myeloma and this time was admitted for acute kidney injury, acute hepatitis, acute heart failure. He is taking of herbal medication.
        • We were consulted for acute on chornic heart failure.
        • S:
          • self complaint bilateral lower limbs edema, SOB just after receiving immuno-target therapy (new) in Feb 2022
          • no Chest tightness, no PND, no orthopnea
        • P/E:
          • Conjunctiva : pale
          • Chest : coarse breathing sounds,
          • Heart : no audible murmur
          • Extremities : 4+ pitting edema up to scrotum
        • Vital sign
          • BT: 36.8 RR: 18 BP: 90/60 HR: 80 SpO2: 99% under NC 3L/m
          • Chest : coarse breathing sounds
          • Heart : tachycardia
          • Extremities: 4+ pitting edema up to scrotum
        • Labs
          • Hb: 8.6 MCV: 105
          • WBC: 22k CRP: 9 neutrophil:81%, band : 5.1%
          • PLT: 61
          • Albumin : 3.2 Globulin : 5.3
          • T.bilirubin : 1.09 (05/30) –> 2.19 (06/14)
          • GOT: 19 –>2472 ; GPT: 9 –> 1630
          • INR: 1.24 –> 1.92
          • BUN: 30 (05/30) –> 60 (06/14)
          • Cr: 1.88–> 3.80
          • NT-proBNP: 6013–> >25000
          • hsTrop : 182 —>1040 ; CPK/CKMB: 1571/12.8
          • Na/K: 129/6.0
        • Urine analysis : pyuria; bacteriuria
        • CXR: cardiomegaly
        • 2022/06/15 Echocardiography:
          • LVEF 77%, LV:45/24, IVS/PW:19/14, LA:50, dilated LA,Ao,RA,RV,PA,IVC, biventricular hypertrophy, poor RV systolic function, adequate LV systolic function, abnormal septal wall motion due to RV failure, impaired LV relaxation, moderate MR,PR, severe TR, minimal amount pericardial effusion, No tamponade, No pericardial cons
        • MRI (02/2022) –> RA/RV dilatation.
        • EKG:
          • Af
          • Poor R wave progression
          • Q-wave in antero-septal leads.
        • Previous immune and target therapy history
          • Daratumumab
          • Bortezomib
        • Impression
          • Heart failure with preserved EF, H2FPEF score: 6,
          • Acute on chronic renal failure with oliguria.
          • Proxysmal Af with CHADVASC score 1 point
          • Acute hepatits, etiology? congestive liver, acute HBV reactivation or herbal medication related
          • Urinary tract infection under brosym
          • Macrocytic anemia
        • Suggestion
          • Restrict salt and water intake
          • Push up IV lasix dosage to increase urine output, such as IV lasix 2amp Q8H or Q6H.
          • Consult nephrologist for acute on chronic renal failure with oliguria. This might be the major etiology of generalized edema.
    • 2022-05-04 Infectious Disease
      • Q
        • For redness, swelling, pain, and blisters on the inner thighs, suspected cellulitis
        • This 64-year-old man, a patient of multiple myeloma, IgG Lambda Dx in Sep 2010 at our H S/P C/T. He was admitted due to pain at thights. He complained of redness, swelling, pain, and blisters on the inner thighs since 20220427. We need expertise to evaluate his condition thanks!
      • A
        • 64-year-old multiple myeloma male patient has bilateral medial thigh and scrotal cellulitis with severe sepsis.
          • Blood culture showed raoultella ornithinolytica bacteremia on May 1.
          • Under ceftazidime use, there is clinical improvement with defervescence, more stable vital signs and partial resolution of local erythema and swelling.
        • Suggestion:
          • Continue ceftazidime.
          • Add ciprofloxacin 400mg iv qd as combination therapy.
          • Arrange scrotal echo.
          • Needle aspiration of bullae fluid and send for bacterial culture (maintain bullae skin intact).
    • 2022-02-17 Infectious Disease
      • A
        • This 64-yera-old man, a patient of multiple myeloma S/P C/T. The blood culture yielded Serratia marcescens S/P Tapimycin for 7 days. but repeat blood culture via port-A later fever with chills on 20220217 morning. Cr: 1.87
        • Suggestion:
          • Agree with your use of finibax for Serratia marcescens bacteremia.
          • Consider to remove the Prot-A if persistent fever.
          • Arrange CV-echo to exlcude endocaridits.
    • 2022-02-14 Nephrology
      • Q
        • for both lower legs edema R/O nephrotic syndrome
        • This 64-year-old man, a patient of Multiple myeloma not having achieved remission S/P C/T. He was admitted due to dyspnea & both lower legs edema. Owing to dyspnea & both lower legs edema progression were noted and high NT-proBNP (5207) and Albumin 2.7–>3.2 post Albumin support. We need expertise to evaluate his condition thanks!
      • A
        • This 64 years old male patient of MM not having achieved remission. He was admitted to Dyspnea and lower leg edema progression. Consult for nephrotic syndrome.
        • Lab data :
          • Albumin: 3.2, BUN:22, cre:1.65
          • Na: 142, K: 4.3, Uric acid: 5.6, LDH: 179
          • PE: slight dyspena under nasal 3 L, Bilateral lower limb edema +++
          • Chest echo : bilateral pleural effusion (rt>lt)
          • Cardiac echo :LVEF: 68%, normal resting wall motion
          • MRI retroperitonium : splenic mass, no retroperitoneal lesion
        • Impression:
          • Nephrotic syndrome? due to multiple myeloma?
        • Suggestion:
          • Check urine for analysis
          • Check UPCR, UACR, lipid profile
          • Keep albumin + diuretic
          • Check ANA, ANCA, antiGBM, antidsDNA, C3, C4, HBV, HCV, syphilis, cryoglobulin, serum free light chain, IgA, IgM, IgE
    • 2022-02-11 Cardiology
      • Q
        • for high NT-proBNP & suspected heart failure
      • A
        • PMH: case of multiple myeloma s/p Daratumumab QW plus Bortezomib / Dexa
        • S: shortness of breath for 3 days, bilateral lower limbs edema noted for about half month. coincide with target therapy. denied of chest pain or discomfort.
          • P/E:
            • 2 consecutive days fever
            • abdominal type respiration, N/C support 5L/m
            • chest : reduced breathing sounds over bilateral lower lungs fields, inspiratory crackles
            • heart : regular heart beats, apical systolic murmur
            • Extremities : 4+ pitting edema
          • Labs
            • PCT:5.27, Blood culture: GNB
            • pro BNP: 5200
            • BUN/Cr: 27/1.59
          • I/O: +380+loss
            • albumin : 2.7–>3.3 (albumin supplement)
          • Current medication
            • po aldactone 1#bid
            • iv tapimycin
          • Recent medication
            • albumin + iv lasix
          • EKG:
            • 2022/01/24 QS wave in V1-3, poor R wave progression
          • CXR: bilateral pleural effusion (right>left) + perihilar congestion
          • Echo (07/21) :EF: 65%
        • Impression
          • heart failure with educed or preserved LVEF(?) or noncardiogenic lung edema
          • GNB sepsis
          • Multiple myeloma
          • prior hypoalbuminemia 2.7 –>3.3
        • Suggestion:
          • Arrange 2D echography to assess the LV function deterioration or not
          • Restrict salt and water intake, Iv lasix use with keep negative I/O balance, record BW. To precise record I/O, consider foley insertion
          • maintain serum albumin level at upper limit at least 3.5 mg/dL to avoid lower level of oncotic pressure
          • Chest echo and thorcacocentesis if possible.
          • F/u electrolyte and renal function
          • Treat sepsis first and underlying as your expertise.
  • chemoimmunotherapy
    • 2022-01-26 - daratumumab 16mg/kg 1300mg 4hr
    • 2022-01-21 - bortezomib 1.3mg/m2 2.5mg SC 5min
    • 2022-01-18 - daratumumab 18mg/kg 1296mg 7hr + bortezomib 1.3mg/m2 2.5mg SC 10min
    • 2022-01-15 - bortezomib 1.3mg/m2 2.5mg SC 5min
    • 2022-01-12 - daratumumab 8mg/kg 631mg 4hr
    • 2022-01-11 - daratumumab 600mg 4hr + bortezomib 1.3mg/m2 2.5mg SC 1hr

[assessment]

  • 2022-09-23 2D transthoracic echocardiography showed dilated RA and RV, impaired RV systolic function and possible moderate pulmonary hypertension.
  • Vasoreactive patients with pulmonary arterial hypertension may benefit from high dose calcium channel blockers, although this treatment may cause hypotension as an adverse reaction. (ref: https://doi.org/10.1093/eurheartj/ehac237 ) The patient’s recent blood pressure reading is approximately 100/75. Adding CCB immediately would not be recommended at this time.

700813596

220922

{adenocarcinoma of rectosigmoid, not completed}

  • exam finding
    • 2022-08-08, -08-04 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • 2022-06-16 Whole body PET scan
      • Multiple glucose hypermetabolic lesions in the right and left lobes of the liver, compatible with multiple liver metastases.
      • Multiple glucose hypermetabolic lesions in the abdominal left and right paraaortic areas. Multiple lymph node metastases should be considered first.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2022-06-04 CT - abdomen
      • Colon cancer s/p operation. Multiple liver metastases (mild progression).
    • 2022-01-14 CT - abdomen
      • Three liver metastases S/P C/T show complete response.
      • Two liver metastase S/P C/T show stable disease.
    • 2021-09-03 CT - abdomen
      • Five newly-developed liver metastases are suspected.
      • Please correlate with sonography and MRI.

701353650

220921

[subjective]

  • bloody stool since 2021-02
  • tenesmus since 2021-03

[objective]

  • exam findings
    • 2022-07-14 Sigmoidoscopy
      • Rectal cancer s/p OP with anastomostic leakage, with healing
    • 2022-07-08 CT - abdomen
      • There is no focal wall thickening at the rectum. Please correlate with colonoscopy.
      • S/P ileostomy at RMQ abdominal wall.
    • 2022-05-09 Patho - colon segmental resection for tumor
      • PATHOLOGIC DIAGNOSIS
        • Tumor, rectum, Robotic assisted TaTME (s/p CCRT) — Adenocarcinoma, residual
        • Resection margins, ditto — Free from tumor
        • Lymph nodes, mesocolic, dissection — Tumor metastasis (11/17) with extracapsular extension (2/11)
        • AJCC pathologic stage — ypT3N2b, stage IIIC, if cM0
      • MICROSCOPIC EXAMINATION
        • Histology: adenocarcinoma
        • Histology Grade: G2, moderately differentiated
        • Depth of invasion: pericolonic fat
        • Angiolymphatic invasion: present
        • Perineural invasion: present
        • Discontinuous extramural tumor extension: absent
        • Circumferential (radial) margin of rectosigmoid: not involved
        • Lymph node metastasis, mesocolic: tumor metastasis (11/17)
        • Lymph node metastasis, IMA / SMA: N/A
        • Extranodal involvement: present (2/11)
        • Pathological TNM Stage: ypT3N2b
        • Type of polyp in which invasive carcinoma arose: N/A
        • TNM descriptors: y
        • Tumor regression grading S/P CCRT: G3
    • 2022-04-12 CT - abdomen
      • Mild regression of rectal cancer.
    • 2022-04-12 Sigmoidoscopy
      • Findings:
        • Rectal cancer s/p CCRT at 5 cm from AV , (right lateral ~ left anterior)
        • DRE: relative fixed (DRE = digital rectal examination)
      • Diagnosis:
        • Rectal cancer s/p CCRT with significant tumor regression
    • 2022-01-28 Cardiopulmonary Exercise Testing
      • conclusions
        • maximal exercise/ submaximal exercise
        • normal exercise capacity ( VO2 102%, WR 114%)
        • normal stroke volume response during exercise
        • normal ventilatory function ( FVC 99%, FEV1 103%)
        • normal respiratory muscle strength (MIP 95%, MEP 73%)
      • suggestions:
        • treat underlying condition
        • arrange pulmonary rehab with exercise training for his CCRT with decline of activity
    • 2021-12-29 CT
      • Findings
        • There is wall thickening at the rectum measuring 2 cm in wall thickness that is c/w adenocarcinoma.
          • In addition, at least six enlarged lymph nodes in the perirectal space and adjacent mesocolon are noted.
        • There are several hepatic cysts in left lobe and the largest one 3.7 cm in size at S2/4.
      • Impression (Imaging stage): T3N2aM0, stage IIIB
    • 2021-12-24 Patho - colon biopsy
      • Rectum , 4 cm from AV, biopsy - Adenocarcinoma.
      • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
  • surgical operation
    • 2022-05-06
      • Surgery
        • Robotic assisted TaTME
      • Finding
        • Rectal cancer s/p CCRT with tumor regression
        • Tumor location : 5 cm from Av   
        • Anastomosis using circular staple CDH 33 at dentate line
  • radiotherapy
    • 2022-01-13 ~ 2022-02-25 - 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed area
  • chemoimmunotherapy
    • 2022-09-20 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-09-01 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-08-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-08-04 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 430mg/m2 730mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-07-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 430mg/m2 730mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-07-05 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 430mg/m2 730mg 10min + fluorouracil 2400mg 4375mg 46hr
    • 2022-06-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-04-15 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-03-25 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-03-09 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 430mg/m2 750mg 10min + fluorouracil 2400mg 4300mg 46hr
    • 2022-02-18 - leucovorin 20mg/m2 35mg 10min D1 + fluorouracil 400mg/m2 700mg 10min D1 (CCRT)
    • 2022-02-16 - leucovorin 20mg/m2 35mg 10min D1-D3 + fluorouracil 400mg/m2 700mg 10min D1-D3 (CCRT)
    • 2022-01-18 - leucovorin 20mg/m2 35mg 10min D1 + fluorouracil 400mg/m2 700mg 10min D1 (CCRT)
    • 2022-01-17 - leucovorin 20mg/m2 35mg 10min D1 + fluorouracil 400mg/m2 700mg 10min D1 (CCRT)
    • 2022-01-12 - leucovorin 20mg/m2 35mg 10min D1-D3 + fluorouracil 400mg/m2 700mg 10min D1-D3 (CCRT)

==========

2022-09-21

In the last three months, both AST and ALT have increased.

Oxaliplatin has been associated with hepatotoxicity, including elevated transaminases and alkaline phosphatases. Peliosis, nodular regenerative hyperplasia or sinusoidal abnormalities, perisinusoidal fibrosis, and veno-occlusive lesions have been detected on liver biopsy. Patients with portal hypertension or increased liver function tests, which cannot be attributed to liver metastases, should be evaluated for hepatic vascular disorders.

2022-02-17

  • current treatment introduced just about a month, have to wait and see the response.
  • available CEA, CA199 readings never outranged normal limits, might not sensible enough for this patient.
  • Zoloft (sertraline 50mg QD) and Rivotril (clonazepam 0.5mg HS) are prescribed for the anxiety.
  • no drug allergy recorded in database, no issue with current medication.

700382077

220920

  • lab data
    • 2022-09-19 Varicella-zoster virus PCR Undetectable
    • 2022-09-15 EB VCA IgG Positive Ratio
    • 2022-09-15 EB VCA IgG Value 6.3 Ratio
    • 2022-09-14 EB VCA IgM Negative Ratio
    • 2022-09-14 EB VCA IgM Value 0.2
    • 2022-09-14 VZV IgM Negative Ratio
    • 2022-09-14 VZV IgM Value 0.1 Ratio
    • 2022-09-12 RPR/VDRL Nonreactive
    • 2022-09-12 HBsAg Nonreactive
    • 2022-09-12 HBsAg (Value) 0.28 S/CO
    • 2022-09-12 Anti-HBc Reactive
    • 2022-09-12 Anti-HBc-Value 3.65 S/CO
    • 2022-09-12 Anti-HCV Nonreactive
    • 2022-09-12 Anti-HCV Value 0.06 S/CO
    • 2022-09-12 CMV IgM Nonreactive
    • 2022-09-12 CMV IgM Value 0.19 Index
    • 2022-09-12 CMV_IgG Reactive
    • 2022-09-12 CMV_IgG Value 87.1 AU/mL
    • 2022-09-12 HIV Ab-EIA Nonreactive
    • 2022-09-12 Anti-HIV Value 0.07 S/CO
    • 2022-09-12 Anti HTLV I/II Nonreactive
    • 2022-09-12 Anti HTLV I/II Value 0.07 S/CO

==========

2022-09-13

  • Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.

  • Febuxostat differs from allopurinol in a number of ways:

    • It is not a purine base analog; because of the non-purine structure, febuxostat inhibits both reduced and oxidized forms of xanthine oxidase and has minimal effects on other enzymes involved in purine and pyrimidine metabolism.
    • Dose adjustment is not needed in patients with mild to moderate renal impairment.
    • There are fewer drug-drug interactions with febuxostat than with allopurinol.
    • It is quite a bit more expensive than allopurinol, at least partly because allopurinol is available as a generic preparation.
  • Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.

  • In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)

  • Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.

  • As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.

  • Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.

  • As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.

701192939

220920

  • exam findings
    • 2022-09-19 Tc-99m MDP whole body bone scan
      • Increased activity in the L5 spine and sacrum, the nature is to be determined (post-traumatic change, DJD or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in both rib cages, some T- and L-spine, bilateral shoulder, S-I joints, and hips.
    • 2022-09-15 CT - chest
      • Esophageal cancer at lower third with tumor regression. However, extensve miliary lung meta is found which progressed signficantly.
      • Mediastinal lymphadenopathy, stable.
    • 2022-09-13 CXR
      • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
      • Atherosclerotic change of aortic arch
      • Pleura thickening in bilateral apical lung area.
    • 2022-08-09 CXR
      • Atherosclerotic change of aortic arch
      • Pleura thickening in bilateral apical lung area.
    • 2022-06-15 CT - abdomen, pelvis
        1. S/P feeding jejunostomy at left upper pelvis.
        1. S/P drainage tube insertion via right upper abdominal wall and the tip located at left pelvis.
    • 2022-06-09 CXR
      • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
      • Thoracic aortic arch calcified atheriosclerotic plaque
      • biapical fibrothoraces
      • reticular opacities over RUL based on plain image
    • 2022-06-07 MRI - brain
      • No brain nodule or metastasis.
    • 2022-06-06 Whole body PET scan
      • Glucose hypermetabolic lesions in the middle esophagus, compatible with the primary esophageal cancer.
      • Glucose hypermetabolic lesions in bilateral mediastinal space and celiac chain lymph nodes, highly suspected cancer with regional lymph nodes involvement, suggesting biopsy for investigation.
      • Glucose hypermetabolic lesions in the left pulmonary hilar region and left supraclavicular fossa, probably reactive nodes or metastatic lymph nodes, suggesting further investigation.
      • Increased FDG accumulation in bilateral kidneys and ureters, probably physiological uptake of FDG.
      • Middle esophageal cancer, cTxN3M0, stage IVA (AJCC, 8th ed.), by this F-18 FDG PET scan.
    • 2022-06-04 CT
      • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T3N2M0
    • 2022-06-02 Patho - esophageal biopsy
      • DIAGNOSIS:
        • A. Labeled as “Esophagus, 40 cm from incisor”, biopsy (A)— squamous mucosa with high grade dysplasia.
        • B. Labeled as “Esophagus, 35-38 cm from incisor”, biopsy (B)— squamous cell carcinoma, moderately differentiated. IHC stains: p40 (+), CK5/6 (+), Ki-67: 90%.
        • C. Labeled as “Esophagus, 20 cm from incisor”, biopsy (C)— squamous mucosa with low grade dysplasia.
      • MICROSCOPIC DESCRIPTION:
        • A. Section shows squamous mucosa with high grade dysplasia.
        • B. Section shows squamous cell carcinoma, moderately differentiated.
          • IHC stains: p40 (+), CK5/6 (+), Ki-67: 90%. Muscularis propria is not present in this biopsy specimen.
        • C. Section shows squamous mucosa with low grade dysplasia.
    • 2022-06-02 2D transthoracic echocardiography
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR
    • 2022-06-01 ECG
      • first degree AV block
    • 2022-02-11 Patho - esophageal biopsy
      • Esophagus, 28 cm below the incisor, biopsy — High-grade dysplasia
        • The sections show a picture of high-grade dysplasia, composed of squamous epithelim with basal cells proliferation, and atypical cell extends up into upper third of the epithelium. Suggest follow up.
      • Esophagus, 32-35 cm below the incisor, biopsy — Squamous cell carcinoma, moderately differentiated.
        • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Ulcer and granulation tissue are present.
    • 2022-02-10 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA grade A
        • Esophageal tumor, middle esophagus, suspected esophageal cancer, post biopsy (A)
        • Esophageal mucosal lesion, upper esophagus, s/p biopsy (B)
        • Superficial gastritis
        • Gastric angiodysplasia, low body, GC site
      • Suggestion
        • Refer to chest surgeon
    • 2022-02-10 SONO - abdomen
      • Diagnosis
        • Suspected fatty infiltration of pancreas
        • Suboptimal examination of liver due to poor echo window
      • Suggestion
        • OPD f/u
        • Follow liver function test and AFP
        • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
        • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months.
  • consultation
    • 2022-06-08 Radiation Oncology
      • Q
        • This 72-year-old male patient with underlying reflux esophagitis (LA grade A) were noted complained dysphagia since 2022-02. Under the impression of esophageal cancer, he was admitted for complete cancer staging and port-A catheter implanation and laparoscopic jejunostomy on 20220609. The disgnosis was esophageal squamous cell carcinoma with mediastinal lymphadenopathy, cT3N3M0, stage IVA. However, the patient wants to discahrge after the surgery done on 20220609 due to personal reason. We recommend CCRT to be arranged during OPD f/u. As a reason, we need your expertise to evaluate this patient and arranged radiotherapy for him. Thank you very much for your kind help!
      • A
          1. Subjective:
          • I. Previous RT: denied.
            1. Other disease: reflux esophagitis (LA grade A).
            1. Family history: denied.
            • A. Habit: Alcohol: wine and beer for 40 yr; Smoking: 2 PPD for 40 yr; betel nut: 80#/day for 40 yr.
            • B. Married. Caregiver: his son (n=2), daughter (n=1), wife. Job: Labor. Mild economic stress.
            • C. Language: Taiwanese. Mandarin.
            • D. Religion: Buddism.
          1. Objective:
          • I. General Condition-ECOG: 1.
            1. PE, 2022/06/08: No palpable SCF LNs.
            1. Pathology, 2022/02/21: Esophagus, 32-35 cm below the incisor, biopsy — Squamous cell carcinoma, moderately differentiated; 28 cm below the incisor, biopsy — High-grade dysplasia.
            1. 2022/06/02: A. Labeled as “Esophagus, 40 cm from incisor”, biopsy (A) — squamous mucosa with high grade dysplasia. B. Labeled as “Esophagus, 35-38 cm from incisor”, biopsy (B) — squamous cell carcinoma, moderately differentiated. IHC stains: p40 (+), CK5/6 (+), Ki-67: 90%. C. Labeled as “Esophagus, 20 cm from incisor”, biopsy (C) — squamous mucosa with low grade dysplasia.
          • V. Images:
            • A. PES, 2022/02/20: One ulcerative mucosa lesion with elevated margin and mucosal nodularity/irregularity was noted at middle esophagus, 32-35cm below the incisor, R/O esophageal cancer: s/p biopsy for eight pieces(A). One slightly elevated mucosa lesion with nodularity was noted at upper esophagus, about 28cm below the incisor, s/p biopsy for multiple pieces(B).
            • B. EUS, 2022/06/02: EUS with UM-25R to the main lesion (35-38 cm) showed hypoechoic lesion involve 4th layer of esophageal wall with 1.7 cm in max thickness. EUS to the lesion at 30 cm lesion revealed a hypoechoic area at 2nd layer of esophageal wall measured 0.26 cm. No change in others lesions. At least 9 para esophageal lymph nodes were detected by EUS. Dx: Esophageal cancer, 35-38 cm, T3N3Mx, s/p biopsy. Rule out dysplastic esophageal lesion, 40 cm, s/p biopsy. Rule out dysplasitc esophageal lesion, 20 cm, s/p biopsy .
            • C. Chest CT, 2022/06/04: Minimal bronchiectatic change over right lower lobe with peribronchovascular infiltration is found. Mild bilateral apical pleural thickening is noted. Long segmental wall thickening at middle to lower esophagus is found up to 6.7cm in largest dimension. Some mediastinal lymphadenopathy is noted at both sides. (n=5) There are also some calcified lymph nodes at bilateral mediastinum. No evidence of bilateral pleural effusion. IMP: cT3N2.
            • D. Brain MRI, 2022/06/07: negative.
            • E. PET, 2022/06/06: There were focal or nodular lesions of increased FDG uptake in the middle esophagus (SUVmax early: 26.58, delay: 46.59), bilateral mediastinal space (SUVmax early: 6.55, delay: 11.68), left pulmonary hilar region (SUVmax early: 5.00, delay: 7.65), left supraclavicular fossa (SUVmax early: 3.13, delay: 6.78), and celiac chain lymph nodes (SUVmax early: 4.69, delay: 5.54).IMP: cN3M0.
          1. Diagnosis: Esophageal cancer, L/3, MD squamous cell carcinoma, cT3N3 (cM0), with paraesophageal and perigastric LAP metastasis at least, scheduled port-A catheter implantation and laparoscopic jejunostomy on 06/09; ECOG =1.
          1. Suggest: Radiotherapy.
          1. Goal: Curative (pre-operative).
          1. RT Plan may be designed as the following one:
          • I. Target & Volume: esophageal tumor, LAPs.
            1. Technique: VMAT and IGRT (OBI).
            1. Dose & Fractionation: 5040cGy/28 fractions, with concurrent chemotherapy.
          1. Plan: CCRT is suggested for tumor control. Possible toxicity (esophagitis, pneumonitis) is told. CT simulation is arranged on June 14 15:30pm. Treatment will be started 2-3 days later. Diet education and psychological support is given.
    • 2022-06-08 Hemato-Oncology
      • A
        • Impression:
            1. lower third esophageal squamous cell carcinoma with mediastinal lymphadenopathy, cT3N3M0, stage IVA
        • Suggestion:
            1. Please check HbsAg, AntiHbc, Anti HCV
            1. Arrange port A insertion
            1. We will discuss with patient about further treatment. Arrange our OPD after discharge.
            1. Thanks for your consultation. If there is any problem, please feel free to let us known.
    • 2022-06-02 Gastroenterology
      • A
        • EUS for esophageal SCC staging is indicated.
        • Already arrange EUS on 20220602 10:30.
  • radiotherapy
    • 2022-06-17 ~ 2022-07-25 - 4680cGy/26 fractions (15 MV photon) to stomach, anastomosis and regional lymphatics (CCRT)
  • chemoimmunotherapy
    • 2022-07-29 cisplatin 60mg/m2 100mg 4hr + fluorouracil 800mg/m2 1300mg 24hr D1-4
    • 2022-07-01 cisplatin 60mg/m2 100mg 4hr + fluorouracil 800mg/m2 1300mg 24hr D1-4
      • ref: U2D - Trimodality therapy with cisplatin plus fluorouracil chemotherapy with concurrent radiotherapy followed by surgery for esophageal and esophagogastric junction cancer

==========

2022-07-29

  • In active prescriptions, all oral drugs can be administered by nasogastric tube.
  • It is recommended to monitor for hearing loss prior to (each dose of, if possible) cisplatin; audiometry as clinically indicated.
  • An assessment of neurologic function prior to each course of chemotherapy might be beneficial.
  • There is no issue with the active prescription.

701390560

220920

  • exam finding
    • 2022-09-01 CTA - chest
      • Left pleural effusion. MIld
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Right renal cyst. 9.3cm
    • 2022-07-28 Pure Tone Audiometry
      • PTA:
      • Reliability FAIR
      • Average RE 6 dB HL / LE 6 dB HL
      • bil WNL
    • 2022-07-01 CXR
      • s/p right chest tube in place, its tip directed superiorly projecting over 4th intercostal space
      • expansion of Rt lung with platelike lung atelectasis over Rt lower lung zone
    • 2022-06-29 Patho - thymus tumor
      • diagnosis
        • Thymus, excision — Squamous cell carcinoma of thymus, poorly differentiated,
          • AJCC 8th edition: pStage IVA, pT1aNxM1a
        • F2022-00304 - Pericardium, biopsy — Thymic squamous cell carcinoma, metastatic
      • microscopic description
        • Sections show sheets of poorly differentiated carcinoma infiltrating in fibrous stroma. Focal squamous cell differentiation is seen.
          • The immunohistochemical stains reveal CD5(+), CD20(-), p40(+), CD117(+), CK19(+), TdT(-), CD56(equivocal), and Synaptophysin(equivocal). The in situ hybridization for EBER is negative. The results are in favor of thymic squamous cell carcinoma. The tumor has invaded to the peripheral thymus tissue. The tumor capsule is focally ruptured.
        • F2022-00304 - Section shows fibrous tissue with metastatic carcinoma.
          • The immunohistochemical stains reveal CD5(+), CD20(-), p40(+), CD117(+), CK19(+), and TdT(-). The results are consistent with metastatic thymic squamus cell carcinoma.
    • 2022-06-29 Frozen Section
      • Preliminary diagnosis: Pericardium, biopsy — metastatic tumor
    • 2022-06-28 ECG
      • Normal sinus rhythm
      • Left axis deviation
    • 2022-05-18 CT at Cathay General Hospital
      • Anterior mediastinal tumor, size about 5.0cm in diameter, anoterior to aortic root.
      • suspected thymoma.
  • surgical operation
    • 2022-06-29 VATS excision of mediastinal tumor and PP window.
      • One mass lesion was noted over anterior mediastinum, anterior to ascending aorta, size about 5.0cm in diameter. Multiple pleural military lesions over left pleural cavity and pericardium.
      • Frozen section of pericardial nodule: carcinoma.
      • One 24 Fr. straight chest tube was inserted via right 7th ICS.
  • radiotherapy
    • 2022-07-29 ~ 2022-09-06 - at 4500cGy/25 fractions of the thymus tumor bed area.
  • chemoimmunotherapy
    • 2022-09-19 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 6 600mg 2hr
    • 2022-08-25 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-18 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-11 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-04 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-07-29 - cisplatin 40mg/m2 60mg 2hr (CCRT)

[assessment]

  • Losartan might be held temperately due to a drop in blood pressure (2022-09-20 09:21 96/56mmHg).

  • Blood glucose levels were elevated (2022-09-20 06:40 236 mg/dL). If the reading remains high over the next two days, then antiglycemic interventions might be necessary.

700823225

220919

  • exam finding
    • 2022-08-29 CXR
      • Enlargement of cardiac silhouette.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-06-09 Whole body PET scan
      • In comparison with the previous study on 2021/12/08, the glucose hypermetablism in the confluent right neck and right supraclavicular lymph nodes (Deauville score 5) are a little more evident. However, no prominent glucose hypermetablism was noted in the previous FDG avild lesions in the tonsils and left neck lymph nodes.
      • Mild glucose hypermetablism in the right hip joint, compatible with arthritis.
      • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
    • 2022-06-08 CT - neck
      • Progressive enlargement of LAP of right neck and regression of LAP at left neck, as compared with CT scna on 20211127.
    • 2022-06-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 36) / 112 = 67.86%
      • Indeterminated LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild MR; mild TR.
      • Thick epicardial fat.
    • 2022-06-07 ECG
      • Normal sinus rhythm
      • Right bundle branch block
      • T wave abnormality, consider inferior ischemia
    • 2022-06-07 CXR
      • Enlargement of cardiac silhouette.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2021-12-09 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 26) / 70 = 62.88%
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 1.
      • Normal RV systolic function.
      • Aortic valve sclerosis with trivial AS; mild MR; mild TR; mild PR.
      • Small pericardial effusion without tamponade and constriction sign.
    • 2021-12-08 Whole body PET scan
      • Glucose hypermetablic lesions in bilateral lateral walls of oropharynx (Deauville score 5), compatible with the primary lymphoma.
      • Glucose hypermetablic lesions in bilateral cervical lymph nodes, right SCF and ICF lymph nodes (Deauville score 5), highly suspected lymphoma with lymph node regions involvement.
      • Glucose hypermetablic lesions in a right axilla lymph node (Deauville score 2) and right hip joint (Deauville score 3), probably benign in nature.
    • 2021-12-07 ECG
      • Normal sinus rhythm
      • Right bundle branch block
    • 2021-12-06 CXR
      • Cardiomegaly.
      • Tortuous thoracic aorta.
      • No mediastinal widening.
      • Obliteration of left CP angle.
      • Scoliosis and spondylosis of T-L spine.
    • 2021-12-06 Patho - gingival/oral mucosa biopsy
      • Oropharynx, left, punch biopsy — Diffuse large B-cell lymphoma, GCB type
      • Section shows squamous mucosa with ulcer and infiltration of large pleomorphic tumor cells.
      • The immunohistochemical stains reveal CK(-), LCA(+), CD3(-), CD20(+), CD10(+), BCL2(-), BCL6(+), MUM1(+), CyclinD1(-), CD56(-), p63(-), and p16(-). The Ki-67 is about 80%. The results are in favor of GCB type of diffuse large B-cell lymphoma.
    • 2021-12-03 Nasopharyngoscopy
      • L oropharyngeal cancer with bil neck mets
    • 2021-11-29 Lymph Node Aspiration
      • indication: suspect L oropharyngeal cancer with neck mets
      • Malignancy, positive for carcinoma
    • 2021-11-29 Pure Tone Audiometry, PTA
      • Tymp bil type C
      • ART bil absent
      • PTA:
        • Reliability FAIR
        • Average RE 59 dB HL // LE 69 dB HL
        • RE mild to profound SNHL
        • LE moderate to profound SNHL
    • 2021-11-27 CT - neck
      • Enlarged lymph nodes at both sides of neck with left palatine lesion. Oropharyngeal cancer with bialetral metastatic LAPs should be first considered until proved otherwise.
    • 2021-11-26 Nasopharyngoscopy
      • huge firm level II NM (infection was told and repeated pus aspiration at 中和LMD)
      • fiber = L tonsillar granular tumor with touch bleeding, ENT local tx done
  • consultation
    • 2021-12-07 Oral and Maxillofacial Surgery
      • Q
        • For dental evaluation
        • A case of oropharyngeal tumor with bilateral metastatic LAPs
        • This is a 80 y/o female patient denied systemic disease. This time, she was admitted for cancer work up due to left oropharyngeal tumor with bilateral metastatic LAPs. The left oropharyngeal biopsy pathologic report was pending, but the pathologic report of left neck LN revealed positive for malignancy. Neck CT disclosed enlarged LN at both sides of neck with left palatine lesion. Oropharyngeal cancer with bialetral metastatic LAPs should be first considered until proved otherwise. Due to left oropharyngeal cancer with bil. metastatic LAPs impressed, we need your expertise for pre-RT dental evaluation. Thank you very much!!
      • A
        • This is a 80 y/o female who suffered from Oropharyngeal cancer.
        • O: No obvious tooth decay or residual root is noted
        • P:
          • Teach her how to do home care and OHI (oral hygiene instruction)
          • Suggest scaling at LDC regularly

700999537

220919

[Chief Complaint] for chemotherapy                                         

[Present Illness] This 46-year-old female patient had invasive carcinoma of no special type with focal micropapillay pattern of the right breast cancer, pT2N1M0, stage IIB, ER (postive, +++95%), RP (postive, +++80%), Her-2/Neu(equivocal, 2+), s/p MRM and ALND on 2017/11/30, post chemotherapy with AC 4 times since 106/12-107/03/13. Adjuvant chemotherapy with Taxotere on 108/04/04-6/6 and radiotheratpy.

On 2020/12/01, microinvasive carcinoma of the left breast, AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0. Margins: Negative, Closest margin (7 mm from deep margin). ER (Ab): Positive (60%, moderate intensity), PR (Ab): Negative, HER-2/Neu (Ab): Positive (score= 3+), s/p left partial mastectomy and sentinel lymph node biopsy, radiotherapy (Radiotherapy with 5000cGy/25 ractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area), and status during endocrine therapy.

Followed CT on 2022/1/28 which revealed Four Metastases on both hepatic lobes are highly suspected. Her-2 overexpressed liver metastases were confirmed after liver biopsy. Bone scan revealed a hot spot in the left humeral head, some faint hot spots in bilateral rib cage, upper T-spine, L2-3 spines, lower L-spine, sacrum, bilateral sternoclavicular junctions, upper portion of the sternum, shoulders, and knees in whole-body survey.

Then she recevied C1 Herceptin, Perjenta (840mg) for loading dose on 2022/2/14, Taxotere on 2022/2/15. C2 Herceptin, Perjenta on 2022/3/7 Taxotere on 2022/3/8. C3 Herceptin, Perjenta on 2022/3/28 Taxotere on 2022/3/29. C4 Herceptin and Perjenta on 2022/4/18,Taxotere on 2022/4/19. Followed CT of chest was performed on 5/2 revealed almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 1/28.minimal nonspecific RML inflammation and subtle small nodules inlower lobes of lungs, susggest f/u. Chemotherapy with C5 Herceptin + Perjenta (420mg) on 2022/5/9.Taxotere on 2022/5/10. C6 Herceptin + Perjenta (420mg) on 2022/5/30.Taxotere on 2022/5/31 C7 Herceptin + Perjenta (420mg) on 2022/6/20.Taxotere on 2022/6/21 C8 Herceptin + Perjenta (420mg) on 2022/7/11.Taxotere on 2022/7/12.

Followed up CT of chest on 2022/8/8 revealed 1.almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 5/4 and 2.two small nodules in Rt lung still visualized, susggest f/u.

C9Herceptin + Perjenta (420mg) on 2022/8/29 and Taxotere on 2022/8/30

This time, she was admitted for chemotherapy on 2022/9/18.

  • past history
    • disease
      • right breast cancer, cT2N0M0,stage II
      • HBV
    • operation
      • partial mastectomy and sentinel lymphnode biopsy on 2017-11-30
  • exam finding
    • 2022-08-08 CT - chest
      • indication: breast ca with liver metastases
      • findings:
        • Lungs: two centrilobular nodules at peripheral of RUL and RLL.
        • Mediastinum and hila: no enlarged LN or mass.
        • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
        • Heart: normal in size of cardiac chambers.
        • Pleura: unremarkable.
        • Chest wall and visible lower neck: s/p Rt mastectomy.
        • Visible abdominal-pelvic contents:
          • liver: small residual low attenuated lesion in S6 and no more visible tumors in other segments. many small hepatic cysts also are visible.
          • a gall bladder stone, 1.4 cm.
          • unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
        • Visualized bones: unremarkable
      • Impression:
        • almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 20220504.
        • two small nodules in Rt lung still visualized, susggest f/u.
    • 2022-07-20 SONO - abdomen
      • Diagnosis
        • Liver tumor, right lobe
        • Liver cysts
        • GB stone
      • Suggestion
        • Remission (at least partial) of hepatic metastasis was noted compared to previous echo study. Correlate with CT scan if clinically indicated
    • 2022-05-04 CT - chest
      • Impression:
        • almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 20220128.
        • minimal nonspecific RML inflammation and subtle small nodules in lower lobes of lungs, susggest f/u.
    • 2022-03-18 Nasopharyngoscopy
      • findings: smooth NPx, oropharynx, hypopharynx; Bil. ant. nasal septum blood clot
      • conclusion: epistaxis
    • 2022-02-11 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2017/11/22, the hot spot in the left humeral head and some faint hot spots in bilateral rib cage are new. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings for further evaluation.
      • The lesions in the L2-3 spines, lower L-spine and sacrum are slightly more evident. Degenerative spine disease in a little more severe status may show this picture. However, please follow up bone scan for further evaluation and to rule out other possibilities.
      • No prominent change is noted in the hot spot in the left temporal region of the skull.
    • 2022-01-28 CT - abdomen
      • Four Metastases on both hepatic lobes are highly suspected.
      • The differential diagnosis include HCCs and cholangiocarcinoma.
      • Please correlate with AFP, CEA, CA199 and CA153.
    • 2022-01-19 SONO - abdomen
      • Diagnosis
        • Hepatic tumors, probable metastatic tumors
        • Liver cyst
        • GB stone
      • Suggestion
        • Further investigation of hepatic metastasis
    • 2021-11-05 Gynecologic ultrasonography
      • uterine myoma
    • 2021-07-14 SONO - abdomen
      • Diagnosis
        • Fatty liver, mild
        • Liver cyst
    • 2021-01-13 SONO - abdomen
      • Diagnosis
        • Fatty liver, mild
        • Liver cyst
        • GB stone
    • 2020-11-30 Patho - breast mastectomy with regional lymph nodes
      • pathologic diagnosis
        • Breast, left, partial mastectomy — Microinvasive carcinoma
        • Resection margin, breast, left, partial mastectomy — Free
        • Lymph node, sentinel, left axillary, SLNB — Negative for malignancy (0/2)
        • AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0
      • microscopic examination
        • Histologic type: Microinvasive carcinoma
        • Size of invasive carcinoma: 0.1 x 0.1 x 0.1 cm
        • Histologic grade (Nottingham histologic score): Only microinvasion present (Not graded)
        • Tumor Focality: Three foci of microinvasive carcinoma
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present, intermediate grade
        • Size of DCIS: 1.0 x 0.8 x 0.7 cm
        • Margins: Negative, Closest margin (7 mm from deep margin)
        • Nodal status (sentinel): Negative (0/2)
          • number of lymph node examined: 2
          • number with macrometastases (>2mm): 0
          • number with micrometastases (>0.2~2mm and/or >200 cells): 0
          • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
        • Treatment Effect: No presurgical neoadjuvant therapy received
        • Lymphovascular invasion: Absent
        • Perineural invasion: Absent
      • immunohistochemical study
        • ER (Ab): Positive (60%, moderate intensity)
        • PR (Ab): Negative
        • HER-2/Neu (Ab): Positive (score= 3+)
        • Ki-67: 15%
        • p63: Loss of myoepithelial cells in invasive component
    • 2020-11-26 Lymphoscintigraphy
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed two focal areas of increased accumulation of radioactivity at the left axilla.
      • Impression: Probably twp sentinel lymph nodes at the left axillary region.
    • 2020-11-13 Patho - breast biopsy
      • Breast tumor, left (12, 1.5), core needle biopsy — Ductal carcinoma in situ, intermediate grade
      • Microscopically, the sections show a picture of ductal carcinoma in situ, intermediate grade characterized by some dilated ducts fill with intermediate grade atypical epithelial cells without necrosis and preserved outer myoepithelial cells.
      • Immunohistochemistry of CK5/6 and P63 show preserved myoepithelial cell;
        • ER(strong, diffusely), PR(+, 1-5%);
        • Her2/neu(+, Dako score 3+).
        • Besides, microcalcification is also noted in non-tumor breast tissue.
    • 2020-08-28 Gynecologic ultrasonography
      • uterine myoma
    • 2020-07-13 Mammography
      • Indication: Right breast cancer status post mastectomy on 2017-11-30
      • Final assessment: BI-RADS category 2, Benign finding.
    • 2020-07-13 SONO - breast
      • S/P right mastectomy.
      • Right chest wall hypoechoic tumor, suggest follow up.
      • Developed left breast 12’ region hypoechoic tumor, 0.78x0.47cm, may consider biopsy.
      • BIRADS 4a
    • 2019-11-15 SONO - breast
      • Left fibroadenomas
      • S/P right breast operation
      • BI-RADS: 2. benign finding
    • 2017-11-30 Surgical pathology Level VI
      • PATHOLOGIC DIAGNOSIS
        • Breast, right, radical mastectomy — Invasive carcinoma of no special type with focal micropapillay pattern
        • Resection margin: Free
        • Lymph node, right axilla, lymphadenecomy — Metastatic carcinoma (3/11)
        • Pathology stage: pT2N1(cM0), stage IIB
      • IMMUNOHISTOCHEMICAL STUDY (Reference: S2017-18231)
        • ER (Ab): Positive (+++ 95%)
        • PR (Ab): Positive (+++ 80%)
        • HER-2/Neu (Ab): Equivocal (2+)
          • FISH STUDY (Reference: S2017-18231) Her2/neu Dual probe FISH: NO amplification
        • Ki-67: 60%
        • p53: pOSITIVE (70%)
    • 2017-11-30 Frozen section
      • Malignant female breast neoplasm, upper-outer quadrant;
      • Sentinel lymph nodes, frozen section — Metastatic invasive carcinoma (2/4)
    • 2017-11-30 Lymphoscintigraphy
      • Probably one sentinel lymph node at the right axillary region.
    • 2017-11-18 SONO - hepatobiliary
      • Gallbladder stone (1.25cm).
    • 2017-11-06 Surgical pathoogy Level IV
      • Clinical diagnosis: Lump or mass breast;
      • Diagnosis
        • Breast, right, core biopsy — Infiltrating ductal carcinoma.
        • IHC stains: E-cadherin (+), ER (+,), PR: (+), Her2/neu: equivocal (score=2+), Ki-67: 60%, p53: 70%.
          • Her2/neu Dual probe FISH: NO amplification. (sent out test by Taipei Institute of pathology.)
    • 2017-08-05 Mammography
      • Regional plemorphic microcalcifications noted in inner upper portion of right breast(posterior third), suggest biopsy.
      • BI-RADS: Category 4b: intermediate suspicion-biopsy should be considered.
    • 2017-08-05 Bone densitometry - hip
      • osteopenia
    • 2017-08-05 Flow-volume curve
      • mild lung restriction
    • 2017-08-05 Colon fiberoscopy
      • Colitis with ulcer, sigmoid colon, s/p biopsy
      • Internal hemorrhoid
    • 2017-08-05 Upper GI panendoscopy
      • Reflux esophagitis, lower esophagus, LA clasification grade A   - Rule out Barrett’s esophagus, s/p biopsy   - Ectopic gastric mucosa, upper esophagus   - Superficial gastritis, antrum

700065031

220916

{Olfactory Neuroblastoma}

  • lab data
    • 2022-04-13
      • Anti-HBc Reactive
      • Anti-HBc-Value 5.56 S/CO
      • Anti-HBs 861.40 mIU/mL
      • HBsAg Nonreactive
      • HBsAg Value 0.00 IU/mL
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.07 S/CO
    • 2022-04-02
      • Protein, total 6.6 g/dL
      • Albumin 47.1 %
      • Alpha-1 4.1 %
      • Alpha-2 13.1 %
      • Beta 17.9 %
      • Gamma 17.8 %
      • M-peak Negative
      • A/G Ratio 0.9
      • Haptoglobin 351 mg/dL (30~200)
    • 2022-04-01
      • B2-microglobulin 4.89 mg/L
    • 2022-03-31
      • Ferritin 1475.4 ng/mL
      • Fe (Iron-bound) 35 ug/dL
      • TIBC 271 ug/dL
      • UIBC 236 ug/dL
      • DBI/TBI 21.21 %
  • exam finding
    • 2022-09-14 CT - brain
      • no acute intracranial hemorrhage
      • mucosal thickening in the right nasopharyngeal roof
      • increased soft tissue in the anterior skull base of the sphenoidal sinus and lateral walls of the bilateral ethoidal sinuses.
    • 2022-09-13 Nasopharyngoscopy
      • Rt malignancy optic nerve tumor s/p op and CCRT. uneven NPX.
    • 2022-09-03 Nasopharyngoscopy
      • Scope: smooth NPx, oropharynx, larynx, hypopharynx
      • There’s no nasal septum
      • diffuse prominent vessels with oozing over left inferior turbinate and left lateral nasal wall
      • crust and necrotic tissue over right lateral nasal wall
      • s/p surgicel covered over left inferior turbinate and left lateral nasal wal
    • 2022-08-15 Acoustic radiation force impulse, ARFI
      • results
        • Median 1.75 m/s
        • IQR 0.14 m/s
        • IQR/Median 7.9 %
        • Metavir Score :F2
      • ref
        • degree of liver fibrosis, NHI def; Device ref value (LOGIQ E10)
        • F0 ARFI < 1.3 m/s F0 ARFI < 1.35 m/s
        • F1 1.3 <= ARFI < 1.5 m/s F1 1.35 ~ 1.66 m/s
        • F2 1.5 <= ARFI < 1.81 m/s F2 1.66 ~ 1.77 m/s
        • F3 1.81 <= ARFI < 1.98 m/s F3 1.77 ~ 1.99 m/s
        • F4 1.98 <= ARFI F4 1.99 < ARFI
    • 2022-08-15 SONO - abdomen
      • Parenchymal liver disease
      • Hepatic cysts, bilateral lobes
      • Parenchymal renal disease and renal cysts, both
      • Splenomegaly, moderate
      • Ascites, minimal
    • 2022-07-29 SONO - kidney
      • Bilateral chronic change of both kidneys.
      • Bilateral renal cysts.
    • 2022-07-25 ECG
      • Normal sinus rhythm
      • Right bundle branch block
    • 2022-07-20 MRI - nasopharynx
      • suspected tumor recurrence in the lateral walls of the bilateral ethoidal sinuses.
      • focal mucosal thickening in the right nasopharynx
    • 2022-07-18 CT - abdomen
      • complete regression of right 12th rib soft tissue lesion is found.
      • hepatic and renal cysts
    • 2022-04-13 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
    • 2022-04-11 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 33 dB HL // LE 38 dB HL
      • RE normal to severe SNHL (Sensorineural hearing loss)
      • LE normal to profound SNHL (Sensorineural hearing loss)
    • 2022-03-30 Patho - soft tissue biopsy / simple excision (non lipoma)
      • Soft tissue, right 12th rib, biopsy — Small blue round cell tumor, compatible with metastatic neuroblastoma
      • Microscopically, the sections show a picture of small blue round cell tumor with apoptosis and focal tumor necrosis.
      • Immunohistochemistry shows CK(-), LCA(-), CD56(+), S-100(-), synaptophysin (-) and chromogranin-A(-) for tumor.
      • According to above histopathologic finding and patient’s past history, it is compatible with metastatic olfactory neuroblastoma. Clinical correlation is needed.
    • 2022-03-30 Abdominal Ultrasonography
      • Diagnosis
        • Parenchymal liver disease, suspected early cirrhosis
        • Liver cyst, S7
        • Bilateral renal cysts
        • Splenomegaly
      • Suggestion
        • Ultrasound follow up
    • 2022-03-28 CT - abdomen, pelvis
      • Soft tissue lesion encasing right 12th rib is found. Nature? Suggest contrast enhanced study.
    • 2022-03-26 CT - abdomen, pelvis
      • Diverticulosis in the A-colon and cecum.
    • 2022-03-26 CT - brain
      • bone destruction in the walls of the right maxillary sinus and right ethmoidal sinus, anterior skull base.
      • increased soft tissue in the bilateral frontal, bilateral ethmoidal and bilateral maxillary sinuses.
    • 2022-03-26 Nasopharyngoscopy
      • Scope: Right pulsatile nasal tumor with oozing, nature?
      • Left nose: also some soft tissue or blood clot with oozing
    • 2020-11-13 Patho - paranasal biopsy
      • Diagnosis
        • A. Labeled as “right nasal tumor”, biopsy — malignant round blue cell tumor.
          • IHC stains: CK (-), CD56 (+), granzyme B (-), CD3 and CD20: no predominant sub-population; p16 (-), EBV(-), CD99 (-). feature suggestive of olfactory neuroblastoma, high grade.
        • B. Labeled as “right nasopharynx tumor tumor”, biopsy — malignant round blue cell tumor.
          • IHC stains: CK (-), CD56 (+), granzyme B (-), CD3 and CD20: no predominant sub-population; p16 (-), EBV(-), CD99 (-). feature suggestive of olfactory neuroblastoma, high grade.
      • Microscopic Description
        • A. Section shows benign respiratory eoithelium lined tissue with irregular nests of large round blue cells demonstrating marked crush artifact and small amount of neurofibrillary-like structure.
          • Mitosis is 0-1/HPF.
        • B. Section shows benign respiratory eoithelium lined tissue with irregular nests of large round blue cells demonstrating marked crush artifact and small amount of neurofibrillary-like structure.
          • Mitosis is 0-1/HPF.
    • 2020-11-09 MRI - nasopharynx
      • IMP: D/D: NPC, Inverted palliloma with SCC.
    • 2020-11-06 Nasopharyngoscopy
      • Epistaxis
      • Right chronic sinusitis with polyposis
      • Right nasal tumor with unknown etiology
  • consultation
    • 2022-09-03 ENT
      • Q
        • epigastaxis at bilateral nostril since tonight after nose-picking
        • Denied trauma
        • 2020-12 LinKou CGMH diagnosed Olfactory Neuroblastoma
        • Hx of epistaxis
        • NKA
        • PH: HT, Rt malignancy optic nerve tumor s/p op and CCRT last Dec. at CGMH
        • 2022-02-25 CT 1. No contrast extravasation (CE), neither pseudoaneurysm (PSA) 2. Hyperemic area lateral to the left pterygoid plate could be acute inflammation change or tumor vessels. 3. S/P change with soft tissue thickening surround the anterior skull base and fovea ethmoidale. 4. Thickening of mucoperiosteum of paranasal sinus, suggestive of chronic sinusitis. 5. Bone destrction/errsion of the right maxillary antral walls, right ethmoid lateral wall and roof. 6. Effacement of the bil. nasopharyngeal recess. 7. A score 2 LN at left neck zone II 8. Left mastoid focal mastoiditis at lower part. 9. No definite active lesion in the scanned lungs and intracranial cavity; IMP: 1. S/P change with soft tissue thickening surround the anterior skull base and fovea ethmoidale. 2. No contrast extravasation (CE), neither pseudoaneurysm (PSA)
      • A
        • S: Bil. epistaxis since this evening
          • According to the patient and medical record:
          • Right olfactory neuroblastoma s/p op and CCRT at CGMH in 2020/12
          • massive epistaxis history in 2022/02, TAE was suggested by CGMH but not done
          • intermittent epistaxis since then
          • under chemotherapy due to metastatic neuroblastoma (Rib) since 2022/04 (Dr. Xia HeXiong), but hold recently due to impaired renal and marrow function
        • O:
          • oral cavity and oropharynx: mild blood clots over post. pharyngeal wall
          • Scope: smooth NPx, oropharynx, larynx, hypopharynx
          • There’s no nasal septum
          • diffuse prominent vessels with oozing over left inferior turbinate and left lateral nasal wall
          • crust and necrotic tissue over right lateral nasal wall
        • A:
          • epistaxis
        • Plan:
          • s/p surgicel covered over left inferior turbinate and left lateral nasal wall
          • ENT OPD f/u and suggest back to CGMH for further treatment amd management
          • treat anemia, electrolyte imbalace (Na, K), prolonged APTT, impaired renal function as your expertise
          • supportive care
          • Education done: if bleeding again, keep head downward and mouth open, if persistent bleeding, back to hospital soon
          • Observation for bleeding at ER at least for 1 hour
    • 2022-08-01 Nephrology
      • Q
        • He was admitted of hematuria since 20220725. We follow laboratory data revealed elevated renal function was found (Cre 4.6mg/dL, BUN 43mg/dL), suspect chemotherapy side effects or another cause?
        • We also arranged kidney echo, report showed 1. Bilateral chronic change of both kidneys. 2. Bilateral renal cysts. Now, he still has dark urine today. We need your expertise and evaluation! Thanks a lot! NP楊采諭/VS陳亨翔
      • A
        • Subj/Obj
          • This 51-year-old man patient suffered from right neck mass with mild nasal oozing in 2020/11. Nasopharynx MRI on 2020/11/10 showed NPC, Inverted palliloma with SCC. Right nasal tumor bipsy on 2021/11/13 and pathology showed olfactory neuroblastoma. Right supraomothyoid neck dissection on 2020/12/10. Endoscopic caniofacial ersection, bilateral nasoseptal flap for skull base reconstruction, facia lata transfer on 2020/12/15.
          • Chemotherapy with EP (VP-16 60mg/m2, CDDP 60mg/m2) from 2021/01/07~2021/3/13 for 3 cycles. VMAT radiotherapy from 2021/01/25~2021/03/19 for 6996 cGy/33 fractions. He is also received chemotherapy with EP (Etoposide 80mg/m2 x3, CDDP 25mg/m2 x3) on 2022/4/13(C1), on 2022/5/9(C2), 2022/06/02(C3), 2022/6/24(C4), 2022/07/15(C5).
          • This time, he suffers from fever to 39.5C at home, and his grandson was confirmed case with COVID-19 virus infection before. He also has dark urine since this morning. He came to our emergency for help. At the ER, laboratory data revealed hematuria and bacteriuria (bacteria:2+ /HPF, Leucocyte Ester:1+, Sediment-RBC: >=100 /HPF), elevated CRP (7.89 mg/dL).
          • WBC 2.21, Hb 8.5, Plt 19, Na 142, K 2.9 BUN 43, Cr 1.2 -> 4.6
        • Impression
          • AKI stage 3, due to sepsis or chemotherapy related
          • Neutropenic fever
          • thromocytopenia suspect chemotherapeutic agents induced
          • Hematuria suspect thrombocytopenia related
        • Suggestion
          • check FeNa, urine Na, urine osmo
          • arrange renal echo
          • adequate hydration
          • avoid nephrotoxic agents
          • record I/O and body weight QD
          • recheck urinalysis
          • correct thrombocytopenia
          • follow up renal function , electrolytes and total CO2
    • 2022-03-31 Hemato-Oncology
      • Q
        • This 51-year-old male has past history of
            1. Right malignancy optic nerve tumor under operation and CCRT
            1. Hypertension under medication control.
        • This time, he was admitted with a chief complaint of right waist soreness for two weeks. The sumptom got worsen thus he came to our ER for help.
        • At ER, laboratory data revealed elevation CRP (9.08 mg/dL), Lymphocyte: 9.3 %, normalcytic anemia of HB 8.7 g/dL and impaired renal function of creatinine 1.94 mg/dL.
        • Abdomen CT revealed soft tissue lesion encasing right 12th rib is found.
        • Under the impression of 1) suspect soft tissue lesion of right 12th rib, 2) Hematuria, he was admitted to INF ward for further evaluation and treatment on 2022/03/28.
        • During hospitalization, laboratory data revealed uric acid: 10.1 mg/dL, LDH: 2172 U/L. We need your expertise to evaluate, sincerely thanks.
      • A
        • Impression:
          • Soft tissue lesion encasing right 12th rib
          • Hematuria, cause to be determined
          • Right olfactory neuroblastoma, high grade s/p operation and CCRT at CGMH
          • Hypertension
          • CKD
        • Suggestion:
          • pending soft tissue biopsy result
          • check Ca, total bilirubin/direct bilirubin, haptoglobin, serum eletropheresis (protein EP), Beta-2 microglobulin, check urine cytology
          • may apply CGMH medical history (olfactory neuroblastoma) if patient want to treat in our hospital
          • thanks for your consultation, we would like to follow up this case. If there is any problem, please feel free to let us known.
  • chemoimmunotherapy
    • 2022-05-09 ~ undergoing - etoposide + carboplatin
    • 2022-04-13 - etoposide
    • 2021-01-07 ~ 2021-03-13 - etoposide (3 times)

[note]

  • Tumors that show good differentiation are generally easy to diagnose, but identification of the diagnostic, morphological features is difficult when a tumor is poorly differentiated, therefore, no definitive diagnosis may be possible. Differential diagnosis of small round cell tumors is particularly difficult due to their undifferentiated or primitive character. (Round Cell Tumors: Classification and Immunohistochemistry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686981/ )
  • For sinonasal undifferentiated carcinoma (SNUC) with neuroendocrine features, small cell, high-grade olfactory esthesioneuroblastoma, or sinonasal neuroendocrine carcinoma (SNEC) histologies, systemic therapy should be a part of the overall treatment. Consider a clinical trial and referral to a major medical center that specializes in these diseases. (Head and Neck Cancers NCCN Evidence Blocks Version 1.2022 - February 14, 2022. p.109)
    • Carboplatin/etoposide +- concurrent RT
    • Cisplatin/etoposide +- concurrent RT
    • Cyclophosphamide/doxorubicin/vincristine (followed by RT-based treatment) (category 2B)

==========

2022-06-27

  • The patient has recurrent small blue round cell tumor, olfactory neuroblastoma, high grade, with metastatic lesion around the right 12th rib. He is receiving etoposide + carboplatin chemotherapy for his disease.
  • The patient’s HGB has been low several times since this May. Lab data also showed high haptoglobin (351 mg/dL 2022-04-02) and high ferritin (1475.4 ng/mL 2022-03-31).
    • 2022-06-21 HGB 6.4 g/dL
    • 2022-06-14 HGB 6.8 g/dL
    • 2022-05-04 HGB 5.5 g/dL
  • Anemia, which can impair functional status, is commonly seen in patients with cancer as a complication of both the illness and its treatment with chemotherapy. The incidence of anemia increases significantly with age. Hb levels can be raised with either ESAs or RBC transfusions.
    • ESAs are indicated for patients who have mildly to moderately symptomatic chemotherapy-associated anemia who have no other potentially correctable causes of the anemia, an Hb level <=10 g/dL prior to therapy, and no contraindications to the use of an ESA (eg, prior history of thromboses, surgery, prolonged periods of immobilization or limited activity, or uncontrolled hypertension).
    • RBC transfusion is recommended for patients whose clinical condition indicates the need for immediate correction of the Hb level (eg, severely symptomatic, cardiopulmonary compromise, and need for a rise in Hb before the two to four weeks or more that it may take for ESAs to take effect), and for patients who have established general risk factors for thromboembolic events or uncontrolled hypertension and thus are poor candidates for ESAs.

2022-08-12

[Angiotensin-Converting Enzyme Inhibitors / Angiotensin II Receptor Blockers]

  • Hypertension is observed (SBP 165 +- 20 during this hospital stay).
  • Blood creatinine level remains above 4mg/dL since end of July. 2022-08-12 Cre 4.33 => eGFR 15, CrCl 17.
  • Sevikar (amlodipine 5mg + olmesartan 20mg) 1# QD and Tritace (ramipril 10mg) 1# QD have been prescribed. Ramipril is an angiotensin-converting enzyme inhibitor and olmesartan is an angiotensin II receptor blocker.
  • Studies showed that the combination of an ACE inhibitor and an ARB can lead to worse renal outcomes. Reference: Misra S, Stevermer JJ. ACE inhibitors and ARBs: one or the other - not both - for high-risk patients. J Fam Pract. 2009;58(1):24-27.
  • Recommendation
      1. DC Tritace
      1. Replace Sevikar with Norvasc (amlodipine 5mg) 1# QD, mild to severe kidney impairment: no dosage adjustment necessary
      1. Start administering Entresto (sacubitril 97mg + valsartan 103mg) 36 hours after the last dose of Tritace. Initial 0.5# QD for eGFR <30 mL/minute/1.73m2 patients.

2022-08-16

  • Coadministration of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers may enhance their adverse or toxic effects. US labeling states that concurrent use of telmisartan and ramipril is specifically not recommended. Canadian labeling states that irbesartan and eprosartan are contraindicated for use with ACE inhibitors in patients with diabetic nephropathy, and Canadian labeling for ramipril/hydrochlorothiazide states use with angiotensin II receptor antagonists (ARBs) is contraindicated in patients with diabetes with end organ damage, moderate to severe renal impairment (GFR less than 60 mL/min), hyperkalemia, or hypotensive congestive heart failure. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. If such a combination must be used, monitor patients extra closely for a greater-than-expected response to the combination, including monitoring of blood pressure, renal function, and potassium concentrations.
  • Atanaal (nifedipine 5mg/cap) 2# TIDAC is listed in active prescription. Adapine (nifedipine 30mg/tab) 1# QD might be a better alternative since it has a prolonged release mechanism, which may result in less fluctuation in concentration.

2022-09-15

  • Poor liver and kidney function. Since the end of July 2022, the serum creatinine level has remained above 4 mg/dL, while the BUN level has followed the same trend and reached 90 mg/dL on 2022-09-14. A high AST/ALT ratio is noted, as AST reached 139 U/L and ALT remained at 13 U/L (2022-06-14).
  • PLT has decreased to 6210^3/uL (2022-09-15) from 16710^3/uL (2022-09-02). Thrombocytopenia is a common complication in liver disease and can adversely affect the treatment, limiting the ability to administer therapy and delaying planned procedures because of an increased risk of bleeding. There is a history of epistaxis in this patient and he tends to pick his nose frequently.
  • Hepatic encephalopathy might be the cause of the patient’s diminished expression and hearing ability, which is currently being treated with LACTUL (lactulose).
  • The use of ramipril (in the active prescription currently) in patients with ascites (in case if it develops) due to cirrhosis or refractory ascites should be avoided; however, if the use cannot be avoided, monitor blood pressure and renal function carefully to ensure that renal failure does not occur rapidly (AASLD [Runyon 2013]).

[drug identification]

  • Total 2 drugs for identification.
  • The 1 identified items has been shown as following while the other 1 items still remain unknown:
    • Through (sennoside 12mg) tab: Laxative, Stimulant
      • Indication: Constipation
        • Relieves occasional constipation (irregularity); generally causes bowel movement in 6 to 12 hours
  • These drugs will be sent back to ward by the in-hospital porter.

2022-09-16

  • Tritace (ramipril) is a member of angiotensin-converting enzyme inhibitors (ACEI) and Sevikar (amlodipine + olmesartan) contains a member of angiotensin II receptor blockers (ARB). Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Coadministration of these two medications is not recommended. Adapine (nifedepine 30mg) 1# QD might be an alternative to replace Sevikar.

700129413

220916

  • present illness
    • 2022-09-15 adminnote
      • The 75-year-old female who has history of hypertension and hyperlipidemia with medication control, regular follow-up at Taipei City Hospital YangMing Branch for years.
      • According the patient, she suffered from many bruises noted after lifting heavy objects about three weeks ago, she went to the Clinic for help. At Clinic, the lab showed thrombocytopenia, so she was transferred to NTUH and steoid therapy (30 mg/day, NTUH 20220722). Due to the personal reason, so she came to our Hematology Oncology OPD for help and steoid therapy increase dose to 60 mg/day since 20220803. But it seemed not change the platelet count much. The medication was changed to dexamethasone at last visit.
      • She regular follow-up Hematology Oncology OPD, then the lab of platelet level lower (Plt: 3000/uL), add Danzol on 2022/09/07.
      • This time, she is admitted for mabthera therapy (low dose 100 mg/week). According the family, the patient’s sugar poor control, so regular follow-up Metabolism OPD, and the patient suffered from fatigue, weakness and appetite change, lethargy for one week, then worsening symptoms and consciousness drowsy since this morning. And suspect a tooth is shaking noted, and bleeding noted last night.
  • past history
    • hypertension and hyperlipidemia with medication control, regular follow-up at Taipei City Hospital YangMing Branch for years.
  • VsNote
    • 2022-09-15
      • A patient of ITP with platelet count 3 k/cumm at OPD (current medication with steroid, CSA and Danazol)
      • Admitted for low dose Mabthera.
      • She was found with drowsy and slow response, no headache, corena with LR (+), bilateral.
      • On touch Glucose > 500
      • Assessment
        • Suspected ICH (arrange emergency brain C.T.) (ICH = Intracranial Hemorrhage)
        • Suspected HHNK (aggressive surgar control with RI) (HHNK = hyperglycemic hyperosmolar nonketotic coma)
  • diagnosis
    • 2022-09-15 adminnote
      • Immune thrombocytopenic purpura
      • Essential (primary) hypertension
      • Hyperlipidemia, unspecified
      • Type 2 diabetes mellitus without complications
      • Liver disease, unspecified
      • Other specified diseases of liver
      • Constipation, unspecified
  • exam finding
    • 2022-09-15 ECG
      • Sinus tachycardia
      • ST & T wave abnormality, consider inferolateral ischemia
      • Abnormal ECG
    • 2022-08-22 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver cyst, left lobe
      • Suggestion
        • Please survey hepatitis B and hepatitis C
    • 2022-08-16 Patho - bone marrow biopsy
      • The sections show normocellular marrow (25%). M/E ratio = 10:1 in CD71 stain. The myeloid cells show good maturation with neutrophilia. The megakaryocytes are increased in number and left shift. No increased CD34+ blasts. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2022-08-15 ECG
      • Normal sinus rhythm
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-08-15 CXR
      • A nodular opacity projecting in the left lower lung is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.

[not completed]

  • F/S records and administered insulin units
    • Date QDAC basal bolus QLAC bolus QNAC bolus HS
    • Unit mg/dL unit unit mg/dL unit mg/dL unit
    • 2022-09-17 184 12 7 - - - -
    • 2022-09-16 157 12 7 256 8 141
    • 2022-09-15 435
  • F/S records and administered insulin units
    • Date QDAC basal bolus QLAC bolus QNAC bolus HS
    • Unit mg/dL unit unit mg/dL unit mg/dL unit
    • 2022-07-20 184 12 7 - - - -
    • 2022-07-19 157 12 7 256 8 141 7
    • 2022-07-18 277 12 7 360 7 316 7
    • 2022-07-17 105 12 7 301 7 361 7
    • 2022-07-16 265 12 7 274 7 179 7
    • 2022-07-15 060 0 0 280 7 186 7 (QDPC 190 mg/dL, after taking sugar)
    • 2022-07-14 189 12 7 281 7 319 7
    • 2022-07-13 - - - - - 376 7

[assessment]

  • Blood sugar levels are poorly controlled. The 2022-09-14 Metabolism and Endocrinology OPD prescribed oral hypoglycemic agents - Galvus Met 1# BID and Relinide 1# TIDAC15 might be added to the active medication list as patient-carried items (hold Galvus temporally for the scheduled brain CT due to its metformin content).

701361745

220915

[tube feeding]

The capsule of Nexium (esomeprazole 40mg/tab) should be opened and the small granules poured into drinking water before tube feeding can begin.

700883303

220914

[objective]

  • exam finding
    • 2022-08-01 CT - abdomen
      • Findings
        • s/p LAR with autosuture retention.
        • Infra-renal aortic aneurysm up to 3.1cm in largest dimension is found.
        • Low density area at both lobes of liver are found up to 12.1cm at right lobe. LIver meta is considered. In comparison with CT dated on 2022-04-15, the metastastic lesions are stationary.
        • Some lymphadenopathy are found at hepatic hilum and retroperitoneal region.
        • There is no ascites accumulation at abdominal cavity.
        • Herniation of the small intestines at RLQ is found. No strangulation is found.
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • Visible chest
          • Diffuse nodular lesions (n>50) are found at both lungs. Stable.
          • Calcified coronary arteries is found.
          • Borderline heart size is found.
          • There is no evidence of destructive bone lesion.
          • Suggest clinical correlation
      • Imp:
        • s/p LAR.
        • Metastatic lesions at both lobes of liver and both lungs. Stationary in size and numbers.
    • 2022-04-15 CT - abdomen
      • Multiple metastases on both hepatic lobes and Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space S/P C/T show stable disease .
    • 2022-01-07 CT - abdomen, pelvis
      • finding
        • Prior CT idenified multiple metastases on both hepatic lobe are noted again, mild decreasing in size (the largest one measuring 13 cm (the largest dimension) at S4 and residual right lobe at prior CT and 12.6 cm in current CT).
        • Prior CT identified multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space are noted again, mild decreasing in size.
      • impression
        • Multiple metastases on both hepatic lobes and multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space S/P C/T show partial response.
    • 2021-08-25 CT - abdomen, pelvis
      • finding
        • Prior CT idenified multiple metastases on both hepatic lobe are noted again, mild decreasing in size (the largest one measuring 16.6 cm in the largest dimension at S4 and residual right lobe at prior CT and 13 cm in current CT).
        • Prior CT identified multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space are noted again, mild decreasing in size.
      • impression
        • Multiple metastases on both hepatic lobes and Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space S/P C/T show partial response.
    • 2021-05-21 MRA - brain
      • IMP: No evidence of brain metastasis. Old ischemic insults as descibed. Intracranial artherosclerosis. General brain atrophy.
    • 2021-05-20 CT - abdomen, pelvis
      • IMP: Rectal cancer s/p operation. Right abdominal wall hernia. Mild decreased size of liver and LNs metastases.
    • 2021-02-17 CT - abdomen, pelvis
      • Multiple metastases on both hepatic lobes and the largest one measuring 16.6 cm at S4 and residual right lobe.
      • Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space.
    • 2019-10-28 M-mode Echo
      • Dilated LA and LV; Mildly abnormal LV sytstolic function with global hypokinesia
      • Septal hypertrophy
      • Trivial MR, mild AR, trivial TR and trivial PR
      • Preserved RV systolic function
    • 2019-10-24 CT - brain
      • Impression: Brain atrophy with old left basal ganalia lacunar brain infarcts. Arteriosclerosis.
    • 2018-07-02 Whole body PET scan
      • At least five glucose hypermetablic lesions in both lobes of the liver, rectal cancer with liver mets should be considered.
      • At least two glucose hypermetablic lesions in the LLQ and RLQ of abdomen, rectal cancer with tumor seeding should be considered, suggesting further investigation.
      • Mild glucose hypermetabolism in the mediastinal lymph node and left SCF lymph node, reactive change may show such a picture.
      • Rectal cancer s/p treatment, cTxNxM1b-1c, stage IVB-IVC (AJCC, 8th ed.), by this F-18-FDG PET/CT scan.
    • 2018-06-28 CT - abdomen
      • S/P operation with liver metastases.
      • Gall stones (3-10mm).
      • Small bowel ileus.
    • 2018-06-15 CT - abdomen
      • Post-op at the colon and liver.
      • Liver metastasis.
      • Prominent soft tissue density in RLQ around the terminal ileum, suspected tumor seeding. Suggest follow up.
    • 2018-02-20 CT - abdomen
      • Compatible with rectal cancer with liver meta s/p op. over liver and rectum. No focal tumor is found.
    • 2017-11-15 Abdominal Ultrasonography
      • Diagnosis
        • Parenchymal liver disease
        • Possible liver cyst with calcification
        • Possible surgical artefact in liver dome
        • GB sludge ball with marked distention of GB
        • Poor postprandial contraction of GB, suggestive of obstruction of GB
      • Suggestion
        • Refer to GS for evaluation of cholecystectomy
    • 2017-10-30 Abdominal Ultrasonography
      • GB stones with distended GB, with cholecystopathy; equivocal echo
      • Murphy sign
      • Possible cystic duct stone
      • Dilated bilateral IHD
      • Suboptimal examination of liver and CBD
      • Parenchymal renal disease
    • 2017-10-29 CT - abdomen
      • Distal CBD stone (6mm) with biliary obstruction. Gall stones (7-11mm).
    • 2017-07-28 CT - abdomen
      • Rectal CA wtih liver metastasis, s/p operation
      • Increased perirectal soft tissue.
    • 2017-07-06 CT - lung/pleura
      • Fracture of right clavicle, 4th-9th ribs with pneumothorax and subcutaneous emphysema. Right hemothorax.
      • Gall stones (8-10mm).
    • 2017-04-21 Surgical pathology Level VI
      • pathological diagnosis
        • Large intestine, rectum, LAR — Adenocarcinoma, moderately differentiated
        • Resection margins: Free of tumor
        • Lymph nodes, mesorectal, LAR — Metastatic adenocarcinoma (4/34)
        • Liver, S7, S5 and S3, partial hepatectomy — Metastatic adenocarcinoma (see path: S2017-05994)
        • Pathology stage: Stage IV (pT3N2aM1)
      • microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Perirectal soft tissue
        • Angiolymphatic invasion: Present; Extramural venous invasion: Present
        • Perineural invasion: Not identified
        • Discontinuous extramural tumor extension: Not identified
        • Circumferential (radial) margin of rectum: Uninvolved, 1.5 mm from the margin
        • Lymph node metastasis, mesorectal: Metastatic adenocarcinoma (4/34)
        • Extranodal involvement: Present
    • 2017-04-21 Surgical pathology Level V
      • Liver, S7, S5, S3 & S3, segmental hepatectomy + partial hepatectomy — Metastatic adenocarcinoma, colorectal origin
    • 2017-04-18 M-mode Echo
      • Dilated LA and LV
      • Thick IVS and LVPW
      • Normal LV and RV contractility
      • LV Grade 1 diastolic dysfunction
      • Mild AR, mild MR
    • 2017-04-13 CT - abdomen
      • Rectal cancer with LNs and liver metastases
      • Cstage T3N2aM1a
    • 2017-04-06 Surgical pathology Level IV
      • Rectum, biopsy — Adenocarcinoma. IHC stain of EGFR (+).
      • IHC stains: PMS2 (+), MSH6 (+), using tissue block (S2017-5995T1)
    • 2017-04-05 Colonoscopic polypectomy
      • Endoscopic examination of rectum and colon was done and the scope has been inserted up to the level of cecum. One 8 mm Is polyp is noted at A-colon 70 cm from anal verge, polypectomy done (A), another similar lesion is seen at the 30 cm, polypectomy (B) done. An annular uclerative tumor mass nearly occupying the whole circumferential lumen is noticed at the rectum 7 cm to the anus, Bx done.
  • consultation
    • 2021-05-20 Neurology
      • The patient presented with acute left limbs weakness with right side deviation of gait since 3 days ago. He denied limbs numbness, slurred speech, facial asymmetry.
      • Impression
        • recurrent right subcortical stroke or left cerebellar stroke
      • Suggestion
        • Arrange MRA brain with/without contrast, EKG
        • Keep bokey
        • Normal saline Hydration
        • Keep SBP<220 or DBP<120 mmHg in acute stroke
        • Check D-dimer for rule out Trousseau’s syndrome.
  • chemoimuunotherapy
    • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-08-24 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-07-29 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-07-08 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-05-11 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-04-14 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-03-15 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-02-15 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-01-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-01-05 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-12-14 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-11-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-10-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-10-06 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-09-13 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-08-26 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-08-06 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-07-22 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-06-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-05-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-05-04 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-04-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-03-31 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2021-03-04 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 300mg/m2 500mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (Avastin + FOLFIRI, Q2WK)

==========

2022-09-14

  • CEA lab data

    • 2022-08-19 CEA 2066.02 ng/mL
    • 2022-07-22 CEA 1882.44 ng/mL
    • 2022-06-15 CEA 1801.03 ng/mL
    • 2022-05-03 CEA 1288.14 ng/mL
    • 2022-04-06 CEA 1470.23 ng/mL
    • 2022-02-11 CEA 864.46 ng/mL
    • 2021-12-28 CEA 740.59 ng/mL
    • 2021-11-09 CEA 555.92 ng/mL
    • 2021-09-29 CEA 525.75 ng/mL
  • According to CT scan impressions, the disease had responded to the current treatment (bevacizumab + FOLFIRI) introduced in early March 2021 and remains stable in the recent half year. However, CEA readings have also increased over the past 12 months.

  • Upon confirmation that the disease has acquired resistance, regorafenib might be considered as a subsequent treatment option.

  • The underlying condition HTN appears to be well controlled during this hospitalization. There are no updated hyperlipidemia lab results available for the past two years that could be ordered if clinically indicated.

2022-04-15

  • Recent CT images (2021-08-25, 2022-01-07) showed partial resonses, however lab data showed elevated biomarker levels (CEA 1470ng/mL 2022-04-06 from 525 2021-09-29, CA199 1087U/mL 2022-04-07 from 465 2021-08-19).
  • Current chemotherapy regimen, FOLFIRI plus bevacizumab, has been in use since 2021-03-04 and it should be still effective according to above mentioned exam results.
  • Lab results on 2022-04-06 concerning liver function, renal function, serum electrolytes, and blood cell counts were grossly normal.
  • Hypertension is one of the underlying health conditions that is well managed based on the TPR records during this hospital stay with the prescribed Sevikar (amlodipine + olmesartan).
  • Hyperlipidemia is also listed as a diagnosis and treated with Crestor (rosuvastatin) currently, however, there is no follow up lab data for more than six months. It is recommended that a blood lipid test be performed.

2021-06-21

[Rectal Cancer]

initial presentation

  • 2017-04-07 tenesmus with bloody stool for more than 1 year.

definite diagnosis

  • 2017-04-07 diagnosed with rectal cancer.

disease extent

  • 2017-04-14 proved adenocarcinoma of low rectum with right liver metastasis, cT3N2M1a, stage IVa, suggest LAR with protective ileostomy and partial hepatectomy.
  • 2017-04-21 pT3N2aM1(4/34), stage IVa, with rectal anastomotic leak s/p debridement. RAS WT.
  • 2018-07-05 PET showed liver metastases and may peritoneal seeding, stage IVb-c

treatment

  • 2017-06-23 mFOLFOX6 started
  • 2017-08-18 hold chemotherapy due to chest contusion injury and cholecystitis
  • 2017-11-07 closure of colostomy on 2017-10-19
  • 2018-02-27 refused adjuvant therapy
  • 2021-03-04 Avastin with FOLFIRI Q2WK started

effect and side effect

  • 2018-06-26 CT showed suspected liver metastases
  • 2018-06-28 small bowel obstruction to ER
  • 2021-02-17 CT, ABD:
    • Multiple metastases on both hepatic lobes and the largest one measuring 16.6 cm at S4 and residual right lobe.
    • Multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, mesentery and para-aortic space.
  • 2021-05-20 CT, ABD:
    • Rectal cancer s/p operation. Right abdominal wall hernia. Mild decreased size of liver and LNs metastases.
  • CEA (ng/mL)
    • 2021-05-19 2259
    • 2021-04-26 1870
    • 2021-03-29 3623
    • 2021-01-29 3951
  • CBC 2021-05-21 WBC, RBC, PLT all in acceptable range.

ongoing problem

Objective:

  • 2019-10-24 CT, Brain: Brain atrophy with old left basal ganalia lacunar brain infarcts. Arteriosclerosis.
  • 2021-05-21 MRA, Brain:
    • No evidence of brain metastasis. Old ischemic insults. Intracranial artherosclerosis. General brain atrophy.
  • 2021-05-20 D-dimer 1291ng/mL(FEU)
  • bokey (aspirin, 100mg QD) in active medication.

Assessment:

  • biomarker hint increased probability of inappropriate blood clots.
  • no related clinical symptom recorded.
  • Trousseau’s syndrome not been concluded yet.

Suggestion:

  • keep following up clinical signs indicating the syndrome.

Objective:

  • BP 141/93 at 10:55 on 06-21 (this is the only record for now during this hospitalization)
  • sevikar (amlodipine 20mg, olmesartan 5mg) 0.5 tab QD in active medication.

Assessment:

  • too few data points to tell the trend.
  • preliminary interpretation: BP still in acceptable range.

Suggestion:

  • keep monitor BP and collect more data points

Objective:

  • Cholesterol total 110mg/dL (2020-07-08)
  • Triglyceride 51mg/dL (2020-07-08), 91mg/dL (2019-10-25)
  • crestor (rosuvastatin 10mg) QD in active medication.

Assessment:

  • gathered data showed the stable condition.
  • no new lab data since 2020 Aug.

Suggestion:

  • update lab data.

701432687

220914

  • exam finding
    • 2022-08-29 KUB
      • Post-op with metallic wire retention in upper abdomen.
      • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • 2022-08-25 CT - abdomen
      • Indication
        • Adenocarcinoma of pancreas with peritoneal seeding, cT3NxM1, stage IV s/p laparoscopic Op wt peritoneal tumor excision on 20220803 & s/p laparoscopic gastrojejunostomy on 20220624 at Taipei City Hospital ZhongXing Branch.
    • 2022-08-04 Patho - peritoneum biopsy
      • diagnosis
        • FsA: peritoneum 1, biopsy— Metastatic adenocarcinoma, moderately differentiated
        • FsB: peritoneum 2, biopsy— Aggregation of foamy histiocytes with focal metastatic adenocarcinoma
      • microscopic description
        • A: Section shows fibroadipose tissue with metastatic moderately differentiated adenocarcinoma. The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), WT-1(-), and Calretinin(focal weak +). The results are consistent with pancreatic origin. Please correlate with the clinical presentation and image study to exclude other origin.
        • B: Section shows fibroadipose tissue with aggregation of foamy histicoytes and multinucleated giant cells. Focal metastatic moderately differentiated adenocarcinoma is seen.
    • 2022-08-03 Frozen Section
      • Preliminary diagnosis:
        • FsA: peritoneum 1, biopsy— Metastatic adenocarcinoma
        • FsB: peritoneum 2, biopsy— Aggregation of foamy histiocytes with focal metastatic adenocarcinoma
    • 2022-07-26 Upper GI series
      • UGI series revealed obstruction of duodenum, 3rd portion.
    • 2022-07-26 Patho- pancreas biopsy
      • Labeled as “pancreas”, clinically: 1.8 cm pancreatic uncinate process mass on MRI, needle biopsy — bland pancreatic acinar tissue and bland islet tissue. Please repeat biopsy.
      • IHC stains: CA19-9 (+), CK19 (+), synaptophysin (- to equivocal), CD56 (- to equivocal), Ki-67: <5%.
    • 2022-07-25 Endoscopic Ultrasonography, EUS
      • Pancreatic tumor, uncinate process, s/p EUS-FNA with ROSE
      • s/p gastroenterostomy
    • 2022-07-23 MRI - brain
      • No metastatic lesion over left cerebellar lobe.
    • 2022-07-21 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 25) / 75 = 66.67%
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA; LV diastolic dysfunction, Gr 1
      • Trivial MR, trivial TR and trivial PR
      • Preserved RV systolic function
    • 2022-07-20 Whole body PET scan
      • The pancreatic tumor at ucinate process shown on the previous abdomen MRI reveals glucose hypermetabolism, and the nature is to be determined (pancreatic head malignancy, lymphoma, or others ?), suggesting biopsy for investigation.
      • Glucose hypermetabolism in the muscle layer of the right umbilical region, the nature is to be determined also (post-traumatic change, lymphoma, or others ?), suggesting biopsy for investigation.
      • Probably reactive nodes in the right mediastinum and bilateral pulmonary hilar regions.
      • Inhomogenously increased FDG uptake in the left cerebellum, the nature is to be determined (normal variants, lymphoma, or other nature ?). Please correlate with other clinical findings for further evaluation.
      • Probably physiological uptake of FDG in the colon.
    • 2022-07-19 Flow volume loop
      • poor performance
      • mild restrictive ventilatory impairment
    • 2022-07-12 MRI - pancreas
      • History and indication:
        • Duodenum obstruction suspected P-head tumor
        • Addendum Imaging Report Form for Pancreatic Carcinoma
        • Impression (Imaging stage) : T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE:IA(Stage_value)
    • 2022-07-11 Endoscopic Ultrasonography, EUS
      • Suspicious pancreatic head (uncinate process) tumor or duodenal tumor with duodenal obstruction, s/p biopsy (A)
      • Enlarged major papilla, suspected tumor involvement, s/p biopsy (B)
      • Suspect GB polyp
      • S/p gastrojejunostomy
      • GERD LA Gr.A
    • 2022-07-08 CXR
      • Tortous aorta with calcification is noted.
    • 2022-07-08 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
  • surgical operation
    • 2022-08-03
      • Surgery
        • laparoscopic examination
        • excision of peritoneal tumor, malignancy
      • Finding
        • ascites(-)
        • multiple small seeding tumors over right paracolic gutter, frozen section: adenocarcinoma
  • chemoimmunotherapy
    • 2022-09-13 - gemcitabine 700mg/m2 1000mg 30min + carboplatin AUC 4 200mg 2hr + fluorouracil 1500mg/m2 2000mg 46hr (Due to economic difficulties, the self-paid FOLFIRINOX shifted to Gemzar + PF)
    • 2022-08-24 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 150mg/m2 220mg 1.5hr + leucovorin 400mg/m2 590mg 2hr + fluorouracil 2400mg/m2 3500mg 46 (pre-Op neoadjuvant FOLFIRINOX, 5-FU initialized at a lower dose)

[assessment]

  • Serum uric acid lab data

    • 2022-09-13 Uric Acid 10.1 mg/dL
    • 2022-09-01 Uric Acid 9.0 mg/dL
    • 2022-08-11 Uric Acid 4.8 mg/dL
  • There is a history of gout in this patient, and his serum uric acid level is elevated. One option might be to prescribe Feburic (febuxostat 80mg) 0.5# QD for at least seven days.

  • Lab data: serum creatinine (2022-09-13 2.14 mg/dL <- 2022-09-01 1.20 mg/dL), BUN (2022-09-13 39 mg/dL <- 2022-09-01 23 mg/dL). The patient’s renal function is declining.

  • Male, age 58, 160cm, 45kg => BMI 17.6kg/m2, CrCl 24mL/min, eGFR 32~38mL/min/1.73m2

  • As this patient is mildly thin, an increase in intake is recommended in order to prevent malnutrition and build up some reserve for future treatment.

  • The use of carboplatin has been associated with renal adverse reactions, including decreased creatinine clearance (27%), and increased blood urea nitrogen (14% to 22%). In the next chemotherapy cycle, it might be an option to reduce the dose.

701432850

220914

{not completed}

  • exam finding
    • 2022-09-12 CXR
      • Port-A catheter inserted its tip projecting over carina via left subclavian vein.
      • enlarged cardiac silhoutte may be due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad/ supine position
      • Dilation of pulmonary trunk
      • Rt and Lt subpulmonary effusion
      • hazy increased opacities over both lungs with poor defination of perihilar and lower lobes vessels
    • 2022-09-08 Visceral Angiography over 2 vessels
      • DSA of celiac trunk, SMA and IMA via right common femoral artery puncture revealed:
        • A tumor stain at splenic flexure of colon.
        • No evidence of active bleeding.
    • 2022-09-08 CXR
      • Port-A catheter inserted its tip projecting over carina via left subclavian vein.
      • enlarged cardiac silhoutte may be due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad/ supine position
      • Dilation of pulmonary trunk
      • Rt and Lt subpulmonary effusion
      • reticular opacities over both lungs
      • Elevation of both hemidiaphragms
    • 2022-09-07 Patho - colon biopsy
      • Colorectum, splenic flexure, biopsy — Adenocarcinoma.
    • 2022-09-06 CXR
      • appropriately positioned gastric tube
      • Port-A catheter inserted its tip projecting over carina via left subclavian vein.
      • Thoracic aortic arch calcified atheriosclerotic plaque
      • enlarged cardiac silhoutte may be due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad/ supine position
      • Dilation of pulmonary trunk
      • Rt and Lt subpulmonary effusion
      • reticular opacities over both lungs may be due to interstitial lung edema
    • 2022-09-06 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 41.6) / 111 = 62.52%
      • Thickened AV with mild AR
      • Normal MV with mild MR
      • Concentric LVH, normal LV wall motion
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
      • Moderate pulmonary hypertension
    • 2022-09-05 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Prolonged QT
      • Abnormal ECG
    • 2022-09-05 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
      • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • 2022-08-06 SONO - Nephrology
      • No significant abnormality from echography for both kidneys
      • Urinary retention, suspected neurogenic bladder
    • 2022-07-19 SONO - chest
      • Bilateral thorax: minimal amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
    • 2022-07-18 SONO - abdomen
      • parenchymal renal disease, both
      • pleural effusion, bilateral
    • 2022-07-15 CT - lung
      • Findings
        • Diffuse nodularity at bilateral upper lobes is found. suspected colon cancer meta.
        • Increased pulmonary vasculature is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • There is moderate bilateral pleural effusion.
        • Extensive bilateral chest wall soft tissue swelling is found. suspected hypoalbuminemia related.
      • Imp:
        • Diffuse nodularity at bilateral upper lobes is found. suspected colon cancer meta.
        • Bilateral moderate pleural effusion and chest wall swelling is found.
    • 2022-07-14 Whole body PET scan
      • A glucose hypermetabolic lesion in the left upper abdomen. Colon malignancy near the splenic flexure should be watched out. Please correlate with other clinical findings for further evaluation.
      • A glucose hypermetabolic lesion in the midline pelvic region about sigmoid colon. The nature is to be determined (inflammatory process? malignancy? other nature?). Please also correlate with other clinical findings for further evaluation.
      • Increased FDG uptake in bilateral neck muscles. Physiological FDG uptake is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2022-07-12 Patho - colorectal polyp
      • Colon, transverse, biopsy — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (loss), MSH6 (+), MSH2(+), MLH1 (loss).
    • 2022-07-11 Colonoscopy
      • Probable colon cancer with partial obstruction, proximal T colon, s/p biopsy(A)
      • Suspect colon polyp with focal malignant change, Paris classification 0-Ip, RS junction, s/p biopsy(B)
      • S/p right hemicolectomy
    • 2022-07-08 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Prolonged QT
      • Abnormal ECG
  • consultation
    • 2022-09-12 Cardiology
      • Q
        • For adjusted BP medication
        • This 60 years old female patient had underlying history of DM, hypertension, CHF, CKD stage 5, Right distal foot wet gangrene with local heat s/p BK and Colon cancer under chemotherapy.
        • Hospitalization, shock status with bleeding tedency. transferred to ICU for monitoring.
        • During ICU course, anti-hypertensive agents are combine with to control BP. however, Blood pressure are out of control.
        • We need your spcecialist to adjusted BP medication. Thanks.
      • A
        • For this patient, the present treatment have reaches to maximal dose of anti-HTN agents
        • only catapress 1 bid can be used for BP control
        • For dilysis patient, some patient has intractable hypertension despite of current regimen
        • You can ask nephrologist to increase the ultrafiltration amount, which might contribute the BP lowering effect
        • The target BP is set as 140-150 mmHg
        • If all treatment is effective, you will ask patient or family to buy minoxidil. minoxidil is relatively powerful for BP control.
    • 2022-09-09 Radiation Oncology
      • Q
        • passage bloody stool around 210g suspected tumor bleeding, so we need your help for evaluation. Thanks!!
      • A
        • According to the clinical condition and imaging findings, angiography is indicated.

[assessment]

  • The patient’s blood pressure has been around 190(+-10)/90(+-10), despite taking the following antihypertensive agents as part of the active prescription:

    • Chenday (labetalol 25mg) 0.5# PRNQ12H
    • Apresoline (hydralazine 50mg) 1# Q6H
    • Sevikar (amlodipine 5mg + olmesartan 20mg) 1# BID
    • Doxaben (doxazosin 4mg) 1# Q12H
    • Syntrend (carvedilol 25mg) 1# BID
  • Clonidine can be used for chronic hypertension as an alternative agent. It is not recommended for initial management but may be considered as additional therapy for resistant hypertension in patients who do not respond adequately to combination therapy with preferred agents (ACC/AHA [Whelton 2018]). We have in stock Catapres (clonidine 0.075mg) currently. Oral form immediate release: Initial 0.1 mg twice daily; increase dose in increments of 0.1 mg/day at weekly intervals based on response and tolerability; usual dose range: 0.2 to 0.6 mg/day in 2 divided doses. The manufacturer’s labeling includes a maximum daily dose of 2.4 mg; however, doses >0.6 mg/day are generally not used.

  • In an alternative attempt to lower the blood pressure, currently used Sevikar might also be replaced with Adapine (nifedipine 30mg) 1# BID and Micardis (telmisartan 80mg) 1# QD.

  • Minoxidil (not available in stock) can also act as an alternative adjunctive agent. It should be reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic (eg, chlorthalidone) and a mineralocorticoid-receptor antagonist (eg, spironolactone). It can be used in combination with a beta-blocker to prevent reflex tachycardia. Fluid retention may occur and may require additional diuretic therapy (ACC/AHA [Whelton 2018]; Brook 2022). Oral form initial: 5 mg once daily, increase dose gradually in intervals of >= 3 days; usual effective dose: 10 to 40 mg/day in 1 to 3 divided doses; maximum dose: 100 mg/day in 1 to 3 divided doses. During therapy, if supine diastolic pressure is reduced <30 mm Hg, administer total daily dose once daily; if supine diastolic pressure is reduced >30 mm Hg, administer in divided doses (ACC/AHA [Whelton 2018]; manufacturer’s labeling).

701207878

220913

{MDS, RAEB-1}

  • present illness
    • This 29-year-old man with past history of PMH of depression, insomnia, acute pancreatitis s/p treatment, GERD. His last dose of COVID vaccination was AZ in November 2021.
    • He was admitted due to chest pain and chest tightness which then accidently discovered thrombocytopenia and anemia on 20220217.
  • past history
    • acute pancreatitis
    • GERD
    • depression, insomnia
  • exam finding
    • 2022-03-14 Patho - bone marrow biopsy
      • Bone marrow, post iliac creast, biopsy — Refractory anemia with excess blasts (RAEB-1)
      • Microscopically, the bone marrow shows hypercellularity with hemopoietic components accounting for about 80~90% of the marrow space, and M/E ration of 2-3:1. Megakaryocytes are midly increased in quantity. Focal excess of blast (5%-9%) is noted and highlighted by CD117 and CD34.
      • Immunohistochemical stain reveals MPO(+), CD71(+), CD138(<3%), CD20(<5%), CD10(focal+), TdT(-) and CD68(diffuse +).
      • NOTE: Please correlate with flowcytometry, peripheral blood and molecular cytogenetic study.
    • 2022-02-17 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Compatible with myelodysplastic syndrome.
      • The sections show hypercellular marrow (90%). The M/E ratio = 2:1. Erythroid hyperplasia with megaloblastoid changes in CD71 stain. The megakaryocyte is slightly decreased in number and a few small megakaryocytes can be found. The MPO+ myeloid cells shows left shift and scattered immature myeloid cells in interstitium are present. An increase in CD68+ monocytes (10%), no CD34+ blasts, and increased CD117+ immature cells constitue 20% of marrow cells are evident. The finding is compatible with myelodysplastic syndrome. Suggest bone marrow smear evaluation and clinic correlation.
    • 2020-12-17 CT - abdomen, pelvis
      • Grade C pancreatitis.
      • Grade 4 fatty liver.
  • lab data
    • 2022-06-13
      • EB VCA IgG Positive Ratio
      • EB VCA IgG Value 5.6 Ratio
      • VZV IgG Positive Index
      • VZV-G Value 2.7 Index
    • 2022-06-10
      • RPR/VDRL Nonreactive
    • 2022-06-10
      • CMV_IgG Reactive
      • CMV_IgG Value 179.4 AU/mL
      • CMV IgM Nonreactive
      • CMV IgM Value 0.16 Index
      • HIV Ab-EIA Nonreactive
      • Anti-HIV Value 0.05 S/CO
      • Anti HTLV I/II Nonreactive
      • Anti HTLV I/II Value 0.08 S/CO
    • 2022-04-15
      • HLA A-high rsolution 11:01
      • HLA A-high rsolution -
      • HLA B-high rsolution 13:01
      • HLA B-high rsolution 35:01
      • HLA C-high rsolution 03:03
      • HLA C-high rsolution 03:04
      • HLA DR-high rsolution 09:01
      • HLA DR-high rsolution 14:05
    • 2022-03-04
      • JAK2-single site mutation Undetectable
      • FLT3-D835 mutation Undetectable
    • 2022-03-03
      • BCR/abl Undetectable
    • 2022-02-24
      • FLT3/ITD mutation Undetectable
      • NPM1 mutation Undetectable
      • ANA Negative
    • 2022-02-23
      • LA1 35.2 sec
      • LA2 34.7 sec
      • LA1/LA2 ratio 1.0
      • Anti-ds DNA Antibody <0.5 IU/ml
      • Anti-ENA Sm 0.7 EliA U/ml
      • Anti-ENA RNP <0.3 EliA U/ml
      • Anti-Cardiolopin IgG <0.5 GPL-U/mL
      • Anti-cardiolipin IgM 2.0 MPL U/mL
      • Anti-β2-glycoprotein-I Ab <0.6 U/mL
      • RF <10 IU/mL
      • C3 135.1mg/dL
      • C4 30.8 mg/dL
      • Direct Coomb Test Negative
      • Indirect Coomb Test Negative
    • 2022-02-18
      • MPO stain Positive(3+)
      • CAE stain Positive
      • ANAE stain Negtive
      • CD2 NA
      • CD3 0.38
      • CD4 NA
      • CD5 0.32
      • CD7 48.01
      • CD8 NA
      • CD10 1.24
      • CD11b 20.93
      • CD13 93
      • CD14 1.14
      • CD15 NA
      • CD16 4.2
      • CD19 11.63
      • CD19/kappa NA
      • CD19/Lambda NA
      • CD20 0
      • CD23 NA
      • CD25 NA
      • CD33 99
      • CD34 2.11
      • CD38 NA
      • CD56 0.06
      • CD103 NA
      • CD117 72.82
      • CD138 NA
      • FMC7 NA
      • HLA-DR 91.75
      • MPO NA
      • TdT NA
      • HBsAg Nonreactive
      • HBsAg (Value) 0.38 S/CO
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.08 S/CO
      • Anti-HBc Nonreactive
      • Anti-HBc-Value 0.11 S/CO
      • Anti-HBc IgM Nonreactive
      • Anti-HBc IgM Value 0.10 S/CO
      • Anti-HBs 0.00 mIU/mL
  • chemoimmunotherapy
    • 2022-04-15 ~ undergoing - azacitidine

==========

2022-09-13

  • Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:
    • Date // cre // trough // cyclosporine daily dose
    • 2022-09-12 1.83 163.7 200mg = 100mg 1# BID, PO
    • 2022-09-11 200mg = 100mg 1# BID, PO
    • 2022-09-10 200mg = 100mg 1# BID, PO
    • 2022-09-09 1.41 200mg = 100mg 1# BID, PO
    • 2022-09-08 200mg = 100mg 1# BID, PO
    • 2022-09-07 1.20 200mg = 100mg 1# BID, PO
    • 2022-09-06 200mg = 100mg 1# BID, PO
    • 2022-09-05 1.11 193.8 200mg = 100mg 1# BID, PO
    • 2022-09-04 200mg = 100mg 1# BID, PO
    • 2022-09-03 200mg = 100mg 1# BID, PO
    • 2022-09-02 200mg = 100mg 1# BID, PO
    • 2022-09-01 69.1 200mg = 100mg 1# QD + 100mg 1# BID first dose, PO
    • 2022-08-31 0.94 50mg = 25mg 2# QD, PO
    • 2022-08-30 50mg = 25mg 2# QD, PO
    • 2022-08-29 0.93 50mg = 25mg 2# QD, PO
    • 2022-08-28 50mg = 25mg 2# QD, PO
    • 2022-08-27 50mg = 25mg 2# QD, PO
    • 2022-08-26 1.22 50mg = 25mg 2# QD, PO
    • 2022-08-01 109.6 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-31 150mg = 100mg 1# QD + 25mg 1# BID, PO
    • 2022-07-30 150mg = 100mg 1# QD + 25mg 1# BID, PO
    • 2022-07-29 0.68 150mg = 100mg 1# QD + 25mg 1# BID, PO
    • 2022-07-28 0.74 118.3 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-27 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-26 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-25 0.85 126.9 100mg = 100mg 1# QD, PO
    • 2022-07-24 100mg = 100mg 1# QD, PO
    • 2022-07-23 0.83 100mg = 100mg 1# QD, PO
    • 2022-07-22 100mg = 100mg 1# QD, PO
    • 2022-07-21 0.77 487.1 200mg = 100mg 1# BID, PO
    • 2022-07-20 200mg = 100mg 1# BID, PO
    • 2022-07-19 200mg = 100mg 1# BID, PO
    • 2022-07-18 0.82 220.0 200mg = 200mg QD, IVD
    • 2022-07-17 200mg = 200mg QD, IVD
    • 2022-07-16 200mg = 200mg QD, IVD
    • 2022-07-15 0.73 162.0 200mg = 200mg QD, IVD
    • 2022-07-14 200mg = 200mg QD, IVD
    • 2022-07-13 0.71 200mg = 200mg QD, IVD
    • 2022-07-12 200mg = 200mg QD, IVD
    • 2022-07-11 0.80 172.6 200mg = 200mg QD, IVD
    • 2022-07-10 200mg = 200mg QD, IVD
    • 2022-07-09 200mg = 200mg QD, IVD
    • 2022-07-08 0.67 200mg = 200mg QD, IVD
    • 2022-07-07 82.7 180mg = 180mg QD, IVD
    • 2022-07-06 180mg = 180mg QD, IVD
    • 2022-07-05 150mg = 150mg QD, IVD
    • 2022-07-04 0.65 77.0 150mg = 150mg QD, IVD
    • 2022-07-03 150mg = 150mg QD, IVD
    • 2022-07-02 150mg = 150mg QD, IVD
    • 2022-07-01 0.59 130mg = 130mg QD, IVD
    • 2022-06-30 130mg = 130mg QD, IVD
    • 2022-06-29 0.56 130mg = 130mg QD, IVD
    • 2022-06-28 130mg = 130mg QD, IVD

2022-09-07

  • Alprazolam is metabolized by the enzyme CYP3A4 and the antifungal drugs itraconazole, ketoconazole, posaconazole, and voriconazole are strong inhibitors of this enzyme, which can increase the serum concentration of alprazolam.

  • Each member of the azole class exhibits a unique spectrum of activity, although fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole all demonstrate similar activity against most Candida species. (ref: Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. doi:10.1093/cid/civ933 )

  • While fluconazole is a less strong (i.e. moderate) CYP3A4 inhibitor than voriconazole, it might be a suitable substitute for voriconazole if no other considerations are taken into account. Additionally, a change from 2# to 1# of alprazolam might also be considered.

2022-09-06

  • On 2022-09-05, blood was drawn about one hour before the time of administration for cyclosporine TDM. It is recommended that blood be drawn within half an hour of the time of administration. As of the latest monitoring result, the level is 193.8 ng/mL, which is generally considered to be within the reasonable range (100 to 400 ng/mL). Based on changes in serum creatinine, renal function appears to be slowly declining (but still within normal range). It might take less time to achieve a concentration greater than 400ng/mL by consecutive daily doses of 200mg than it did in mid-July. A retest is recommended after three days to determine if the dose should be adjusted.

  • Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:

    • Date // cre // trough // cyclosporine daily dose
    • 2022-09-06 200mg = 100mg 1# BID, PO
    • 2022-09-05 1.11 193.8 200mg = 100mg 1# BID, PO
    • 2022-09-04 200mg = 100mg 1# BID, PO
    • 2022-09-03 200mg = 100mg 1# BID, PO
    • 2022-09-02 200mg = 100mg 1# BID, PO
    • 2022-09-01 69.1 200mg = 100mg 1# QD + 100mg 1# BID first dose, PO
    • 2022-08-31 0.94 50mg = 25mg 2# QD, PO
    • 2022-08-30 50mg = 25mg 2# QD, PO
    • 2022-08-29 0.93 50mg = 25mg 2# QD, PO
    • 2022-08-28 50mg = 25mg 2# QD, PO
    • 2022-08-27 50mg = 25mg 2# QD, PO
    • 2022-08-26 1.22 50mg = 25mg 2# QD, PO
    • 2022-08-01 109.6 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-31 150mg = 100mg 1# QD + 25mg 1# BID, PO
    • 2022-07-30 150mg = 100mg 1# QD + 25mg 1# BID, PO
    • 2022-07-29 0.68 150mg = 100mg 1# QD + 25mg 1# BID, PO
    • 2022-07-28 0.74 118.3 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-27 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-26 125mg = 100mg 1# QD + 25mg 1# QD, PO
    • 2022-07-25 0.85 126.9 100mg = 100mg 1# QD, PO
    • 2022-07-24 100mg = 100mg 1# QD, PO
    • 2022-07-23 0.83 100mg = 100mg 1# QD, PO
    • 2022-07-22 100mg = 100mg 1# QD, PO
    • 2022-07-21 0.77 487.1 200mg = 100mg 1# BID, PO
    • 2022-07-20 200mg = 100mg 1# BID, PO
    • 2022-07-19 200mg = 100mg 1# BID, PO
    • 2022-07-18 0.82 220.0 200mg = 200mg QD, IVD
    • 2022-07-17 200mg = 200mg QD, IVD
    • 2022-07-16 200mg = 200mg QD, IVD
    • 2022-07-15 0.73 162.0 200mg = 200mg QD, IVD
    • 2022-07-14 200mg = 200mg QD, IVD
    • 2022-07-13 0.71 200mg = 200mg QD, IVD
    • 2022-07-12 200mg = 200mg QD, IVD
    • 2022-07-11 0.80 172.6 200mg = 200mg QD, IVD
    • 2022-07-10 200mg = 200mg QD, IVD
    • 2022-07-09 200mg = 200mg QD, IVD
    • 2022-07-08 0.67 200mg = 200mg QD, IVD
    • 2022-07-07 82.7 180mg = 180mg QD, IVD
    • 2022-07-06 180mg = 180mg QD, IVD
    • 2022-07-05 150mg = 150mg QD, IVD
    • 2022-07-04 0.65 77.0 150mg = 150mg QD, IVD
    • 2022-07-03 150mg = 150mg QD, IVD
    • 2022-07-02 150mg = 150mg QD, IVD
    • 2022-07-01 0.59 130mg = 130mg QD, IVD
    • 2022-06-30 130mg = 130mg QD, IVD
    • 2022-06-29 0.56 130mg = 130mg QD, IVD
    • 2022-06-28 130mg = 130mg QD, IVD

2022-07-29

[recommended cyclosporine daily dose to maintain a stable and reasonable trough concentration]

  • Time serial cyclosporine daily dose and its trough concentration log:
    • Date // trough conc ng/mL // cyclosporine daily dose mg
    • 2022-07-29 200mg ~ 100mg BID
    • 2022-07-28 118.3 100mg ~ 100mg QD
    • 2022-07-27 100mg ~ 100mg QD
    • 2022-07-26 100mg ~ 100mg QD
    • 2022-07-25 126.9 100mg ~ 100mg QD
    • 2022-07-24 100mg ~ 100mg QD
    • 2022-07-23 100mg ~ 100mg QD
    • 2022-07-22 100mg ~ 100mg QD
    • 2022-07-21 487.1 200mg ~ 100mg BID
    • 2022-07-20 200mg ~ 100mg BID
    • 2022-07-19 200mg ~ 100mg BID
    • 2022-07-18 220.0 200mg ~ 200mg QD
    • 2022-07-17 200mg ~ 200mg QD
    • 2022-07-16 200mg ~ 200mg QD
    • 2022-07-15 162.0 200mg ~ 200mg QD
    • 2022-07-14 200mg ~ 200mg QD
    • 2022-07-13 200mg ~ 200mg QD
    • 2022-07-12 200mg ~ 200mg QD
    • 2022-07-11 172.6 200mg ~ 200mg QD
    • 2022-07-10 200mg ~ 200mg QD
    • 2022-07-09 200mg ~ 200mg QD
    • 2022-07-08 200mg ~ 200mg QD
    • 2022-07-07 82.7 180mg ~ 180mg QD
    • 2022-07-06 180mg ~ 180mg QD
    • 2022-07-05 150mg ~ 150mg QD
    • 2022-07-04 77.0 150mg ~ 150mg QD
    • 2022-07-03 150mg ~ 150mg QD
    • 2022-07-02 150mg ~ 150mg QD
    • 2022-07-01 130mg ~ 130mg QD
    • 2022-06-30 130mg ~ 130mg QD
    • 2022-06-29 130mg ~ 130mg QD
    • 2022-06-28 130mg ~ 130mg QD
  • According to the above records, 175 mg per day is more likely to maintain a trough concentration within a reasonable and relatively stable range.

2022-07-22

[cyclosporine concentration]

  • On 2022-07-21, the cyclosporine trough concentration in this patient reached a record high of 487 ng/mL, which is generally considered to be above the normal range.
  • The following adverse reactions and incidences have been reported with systemic use of the drug. Percentages indicate the highest frequency, regardless of indication or dosage. Monitoring these signs might be helpful.
    • Cardiovascular: Hypertension (13% to 53%)
    • Endocrine & metabolic: Hirsutism (21% to 45%)
    • Gastrointestinal: Gingival hyperplasia (4% to 16%)
    • Genitourinary: Urinary tract infection (21%)
    • Infection: Viral infection (16%)
    • Nervous system: Headache (2% to 15%)
    • Neuromuscular & skeletal: Tremor (21% to 55%)
    • Renal: Nephrotoxicity (25% to 38%)
  • In the hospital, capsules containing 100mg and 25mg are available.
  • The recommended dose for oral administration is 100mg for one day followed by 150mg (100mg + 2 x 25mg) for the next two or three days, followed by another TDM to determine whether it is necessary to titrate the dose up to 175mg per day.

2022-07-19

[cyclosporine trough concentration]

  • A trough concentration of 220 ng/mL of cyclosporine was observed on 2022-07-18, which is considered adequate; however, the concentration momentum remains upward.

2022-07-15

[post-transplant immunization

  • Hematopoietic cell transplant (HCT) recipients should be immunized against a number of pathogens such as pneumococcus, Haemophilus influenzae, tetanus, and others once they are likely to mount an immune response.
  • Most live virus vaccines are avoided altogether during the first 24 months following HCT.
  • Certain ones (eg, measles, mumps, and rubella vaccine) are indicated 24 months following HCT in patients who do not have active graft-versus-host disease and who are not receiving immunosuppressive agents.

[cyclosporine trough concentration]

As of 2022-07-14, the trough concentration of cyclosporine was 162 ng/mL, which is considered to be an acceptable level.

2022-07-13

[Cyclosporine trough concentration follow-up]

  • Cyclosporine trough concentration on 2022-07-11 reached 172.6 ng/mL, which was within the range of 100 to 400 ng/mL where the majority of individuals demonstrate optimal responses.

2022-07-08

[Cyclosporine (ciclosporin) concentration]

  • There appears to have been an error in entering the time of blood collection as 2022-07-07 00:00 by the system, and the concentration of ciclosporin was recorded as 82.7 ng/mL.
  • Ciclosporin has been titrated up to 200 mg per day (2020-07-05 09:15 150mg, 2020-07-06 09:17 180mg, 2020-07-07 09:14 180mg, 2020-07-08 08:38 200mg).
  • It should be expected that the new dose (200 mg QD) will reach a steady state at blood levels of more than to 100 ng/mL. This can be checked next Monday (2022-07-11) by TDM.

2022-07-07

[cyclosporine trough concentration]

  • Most individuals display optimal response to cyclosporine with trough whole blood levels 100 to 400 ng/mL. The trough concentration on 2022-07-04 was 77 ng/mL with 150mg IVD administered each day. Please recheck the clinical response to determine if dosage needs to be adjusted.

2022-06-14

Dosage of ATG as part of the conditioning regimen in allogeneic PBSCT from matched sibling donors in patients with hematologic malignancies

  • As can be seen, 4.5~6mg/kg of ATG was used in allogeneic PBSCT from siblings who had been matched, specifically:
    • ATG plus CsA, MTX, and MMF for GVHD prophylaxis with the following details: 3 mg/kg CsA continuous intravenous drip, started on day 21, changed to orally when GI function recovered with a dose of 5 mg/kg administered as 2 divided doses, and CsA trough concentration maintained at 200-300 ng/mL; 15 mg/m2 MTX on day 1 and 10 mg/m2 MTX on days 3, 6, and 11; 0.25 g MMF twice a day, starting on day 21 and continuing to day 30 for 1 month; and 4.5 mg/kg ATG divided in day 23, day 22, and day 21.
    • rATG was administered to 40 patients at an intravenous dose of 5 mg/kg divided over day 5 and day 4 before graft infusion.
    • an ATG dose <6 mg/kg is sufficient for GVHD prophylaxis, while higher doses impair disease control and outcome.
      • ref: Impact of antithymocyte globulin doses in reduced intensity conditioning before allogeneic transplantation from matched sibling donor for patients with acute myeloid leukemia: a report from the acute leukemia working party of European group of Bone Marrow Transplantation. https://pubmed.ncbi.nlm.nih.gov/29330391/

2022-05-19

  • This 29-year-old male was diagnosed with MDS, RAEB-1 during Feb, Mar 2022 and has been receiving azacitidine since April 2022.
  • There is also a possibility of acute leukemia, the patient has been admitted for further evaluation.
  • The underlying diseases are treated with corresponding drugs. No issue with current medication.

700065931

220912

  • exam finding
    • 2022-09-09 ECG
      • Normal sinus rhythm
      • Low voltage QRS
      • Borderline ECG
    • 2022-09-09 Neck soft tissue
      • Increased prevertebral soft tissu thickness. Please correlate with CT.
    • 2022-09-09 CXR
      • Lung markings: increased density in the right lower lung field.
      • blurred right hemidiaphram
      • blunting right costophrenic angle 2022-09-01 Nasopharyngoscopy
      • Findings
        • blood clot at left anterior nasal cavity, bloody discharge at left nasopharynx, bi nasopharynx smooth, multiple whitish spots coating on hypopharynx and supraglottis, favor candidiasis; supraglottis mild edema
      • Conclusion
        • NPC s/p treatment
        • Suspected pharynx and larynx candidiasis
    • 2022-08-31 CXR
      • There is diffuse osteoblastic bony metastases in the T-spine and L-spine?
    • 2022-08-25 Patho - lymph node region resection
      • Labeled as “right axillary lymph nodes”, clinical history of nasopharyngeal carcinoma, dissection — metastatic poorly differentiated squamous cell carcinoma (10/10).
      • IHC stains: CK5/6 (+), p40 (+), p16 (-), EBV (-).
    • 2022-08-25 Nasopharyngoscopy
      • Findings
        • Nasopharynx: smooth
        • Larynx and hypopharynx: epiglottis and bi arytenoid and bi false cord edema, airway small but adequate
      • Conclusion
        • supraglottic edema, suspected RT and intubation trauma related
    • 2022-08-22 Tc-99m MDP whole body bone scan with SPECT
      • Highly suspected cancer with multiple bone metastases in the sternum, both rib cages, scapulae, and several T- and L-spine.
      • Increased tracer uptake in the sacrum, bilateral multiple pelvic bones, S-I joints, and bilateral femurs, bone metastases should be considered, suggesting follow-up with bone scan in 3 months for investigation.
    • 2022-08-19 CXR
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2022-08-18 SONO - chest
      • Diagnosis:
        • Pleural effusion, milk like, favor chylothorax.
        • Chest echography was performed first. The suitable intercostal space was selected and located.
        • Catheter was inserted with negative pressure smoothly.
        • Right side pleural effusion was drawn smoothly.
        • Watch out BP after tapping.
      • Suggestion:
        • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR. TG and amylase.
    • 2022-08-17 CT - lung
      • occlusion of Rt IJV, subclavian and innominate vein, with pleural effusion.
      • bony metastasis and suspect metastatic LNs in axillary regions and mediastinum.
    • 2022-08-17 CXR
      • reticular opacities at LUL due to fibrotic change
      • extensive consolidation over Rt lower lobe and possibly increased opacity over Lt retrocardiac lower lobe
      • mild enlarged cardiac silhoutte
      • widening of Rt paratracheal stripe
    • 2022-08-17 ECG
      • Normal sinus rhythm
      • Low voltage QRS
      • Borderline ECG
    • 2022-07-25 MRI - nasopharynx
      • No local NPx tumor recurrence.
      • Post OP/RT in right parotid gland, with soft tissue swelling and well post contrast enhancement, stationary
      • Sternal notch and chest wall lesion, more likely infection, improved, but seems extending to the mediastinum.
    • 2022-07-18 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis
        • Gastric subepithelial leison (SEL), antrum AW
      • Suggestion
        • No evident esophageal lesion on endsocopy
        • Consider EUS study for the gastric SEL
    • 2022-07-06 Whole body PET scan
      • Glucose hypermetabolic lesions disappear in soft tissues in the suprasternal notch and presternal area compared with the previous study on 2022-01-21, indicating response to current therapy. However, glucose hypermetabolism becomes more evident in the lower portion of the esophagus, and the nature is to be determined (inflammation or other nature?). Please correlate with other clinical findings for further evaluation.
      • Suspected benign lesions in the left aspect of maxilla, in bilateral axillary lymph nodes, and in the proximal portion of right femoral shaft.
      • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
      • No abnormally increased FDG uptake is evidently delineated elsewhere.
    • 2022-06-10 CXR
      • S/P port-A implantation.
      • Fibrosis of left upper lung is noted. Please correlate with clinical history to rule out old inflammatory process.
    • 2022-05-23 Nasopharyngoscopy
      • NPC s/p treatment
      • No evidence of tumor recurrence at nasopharynx
    • 2022-03-10 Nasopharyngoscopy
      • NPC s/p treatment
      • No evidence of tumor recurrence at nasopharynx
      • Lower neck/upper chest wall recurrence under CCRT
    • 2022-01-26 Patho - lymphnode biopsy
      • Tissue, lower neck, subcutaneous, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated
      • The specimen submitted consists of 9 tissue fragments measuring up to 0.7x 0.6x 0.3 cm in size, fixed in formalin. Grossly, they are grayish and solid.
      • Microscopically, it shows nasopharyngeal carcinoma characterized by diffuse sheets or syncytia of non-keratinizing invasive carcinoma infiltrated by lymphoplasmacytic cells.The tumor shows nuclear hyperchromasia, pleomorphism and high N/C ratio.
      • Immunohistochemical stain reveals CK(+), P40(+), and p16(-).
    • 2022-01-21 Whole body PET scan
      • Mild glucose hypermetabolism in the soft tissues in the suprasternal notch and presternal area, in a right axillary lymph node, in two left axillary lymph nodes and in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in the proximal portion of right femoral shaft. The nature is to be determined (post-traumatic change? other nature?). Please also correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in a focal area in the left aspect of maxilla. Dental problem is more likely.
      • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • 2022-01-03 SONO - articular peripheral soft tissue
      • Finding:
        • Heterogeneous hypoechoic poor-defined mass noted over the subcutaneous layer of left SCM at sternal head area, without increased signal under power Doppler.
      • Impression And Suggestions:
        • A poor-defined subcutaneous soft tissue mass, located superficial to the left SCM, sternal head, without increased signal under power Doppler.
    • 2021-12-07 MRI - nasopharynx
      • No local nasopharynx tumor recurrence.
      • Post OP/RT in right parotid gland, with soft tissue swelling and well post contrast enhancement, need follow up.
      • Sternal notch and chest wall lesion, more likely infection.
    • 2021-12-07 SONO - abdomen
      • A hepatic hemangioma or calcification 0.31 cm in S8.
      • A gallbladder polyp 2.3 mm is highly suspected.
    • 2021-08-17 MRI - nasopharynx
      • No nasopharynx tumor recurrence.
      • Post OP/RT in right parotid gland, with soft tissue swelling and well post contrast enhancement, need follow up.
      • Chronic mastoiditis.
    • 2021-06-24 Pure tone audiometry
      • Tymp RE type B, LE type C
      • PTA:
        • Reliability FAIR
        • Average RE 35 dB HL / LE 20 dB HL
      • RE normal to severe MHL
      • LE normal to severe SNHL
    • 2021-04-22 Patho - salivary gland resection
      • pathologic diagnosis
        • Parotid gland, right, parotidectomy — Lymphoepithelial carcinoma involving margins.
        • Superior margin to?, excision — Lymphoepithelial carcinoma involving margin
        • Tissue around trigus, excision — benign parotid gland
        • Deep lobe of parotid, excision — Lymphepithelial carcinoma involving margin.
      • microscopic description
        • Both salivary lymphoepithelial carcinoma and nasopharyngeal lymphoepithelial carcinoma have the same morphology.
    • 2021-04-20 EKG
      • Sinus tachycardia with occasional Premature ventricular complexes
      • Left axis deviation
      • Inferior infarct, age undetermined
    • 2021-04-16 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal ulcer, ECJ, s/p biopsy
        • Reflux esophagitis LA Classification grade B
        • Duodenal shallow ulcers, bulb
        • Duodenal ulcer scar, bulb
        • Gastric erosion, antrum, LC
        • Gastric subepithelial lesion, antrum, AW-GC
        • Superficial gastritis, s/p CLO test
      • Suggestion
        • Persue biopsy result
    • 2021-04-08 Whole body PET scan
      • Some mild glucose hypermetabolic lesions in the right parotid gland. The nature is to be determined (metastases/malignancy of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
      • A glucose hypermetabolic lesion in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • 2021-03-26 Pathology - lymph node
      • Malignancy
      • R’t parotid nodules: one wet and one dry smears show lymphocytes, acinar clusters, and some atypical epithelial clusters with enlarged nuclei and prominent nucleoli, suggestive of carcinoma, and metastatic maybe first considered according to past history.
    • 2021-02-22 MRI - nasopharynx
      • C/W NPC s/p treatement without local reurrence. However, progressive enlargement of right parotid lesions is noted. Suggest further evaluation. Left mastoiditis.
    • 2021-02-22 SONO - abdomen
      • Fatty liver.
      • Gallbladder polyps.
    • 2020-08-06 MRI - nasopharynx
      • No nasopharynx tumor recurrence.
      • Several small nodulated lesions in right parotid gland, stationary in sizes.
    • 2020-02-04 MRI - nasopharynx
      • No nasopharynx tumor recurrence.
      • Several small nodulated lesions in right parotid gland, stationary in sizes.
    • 2019-06-14 MRI - nasopharynx
      • Several small lymph nodes in the right parotid gland, stationary in sizes.
    • 2019-02-19 MRI - nasopharynx
      • NPC, post CCRT. No local tumor recurrence. No neck LAP. A right parotid gland nodule or LN.
    • 2018-08-02 MRI - nasopharynx
      • NPC, post CCRT. No local tumor recurrence. No neck LAP.
    • 2018-04-10 MRI - nasopharynx
      • NPC s/p CCRT with post treatment change.
      • Chronic maxillary sinusitis and left mastoiditis.
    • 2017-11-20 MRI - nasopharynx
      • NPC s/p CCRT with post treatment change.
      • Chronic maxillary sinusitis and left mastoiditis.
    • 2017-08-16 MRI - nasopharynx
      • NPC s/p CCRT with tumor regression.
    • 2017-02-23 Whole body PET scan
      • Glucose hypermetabolism in the nasopharyngeal roof, compatible with primay nasopharyngeal malignancy.
      • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes, bilateral neck level II-V lymph nodes and bilateral supraclavicular lymph nodes. Lymph node metastases may show this picture.
      • Mild glucose hypermetabolism involving the right shoulder, right sternoclavicular junction and left hip, compatible with benign joint lesion such as arthritis.
    • 2017-02-17 MRI - nasopharynx
      • Tumor location/size
        • Bilateral nasopharyngeal roof
        • Size (largest dimension): 34 mm
      • Tumor invasion:
        • T1 (nasopharynx)
      • Neck lymph node:
        • Retropharynx: Rt(+)/Lt(+); Supraclavicular: Rt(+)/Lt(+)
        • Level I: Rt(-)/Lt(-); Level II: Rt(+ab)/Lt(+ab); Level III: Rt(-)/Lt(+ab); Level IV: Rt(-)/Lt(-); Level V: Rt(+ab)/Lt(+ab); Lvele VI: Rt(-)/Lt(-); Level VII: Rt(-)/Lt(-)
          • -: short axis<10 mm,
          • a: short axis>=10 mm;
          • b: long axis >= 15 mm,
          • c: cluster of >= 3 nodes with short axis >= 7 mm,
          • e: extracapsular spread,
          • n: necrosis
      • Distant metastasis in this study:
        • No or equivocal
      • Imaging stage according to AJCC 7th edition:
        • nasopharyngeal tumor.
      • Impression:
        • nasopharyngeal tumor, suspected lymphoma or others.
    • 2017-02-15 Surgical pathology Level IV
      • Nasopharynx, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated (WHO type 2b)
      • IHC stain — CK(+)
      • Microscopically, section shows nasopharyngeal carcinoma characterized by diffuse sheets or syncytia of non-keratinizing invasive carcinoma closely infiltrated by prominent lymphoplasmacytic cells. Nuclei are vesicular with indistinct cell margins, prominent eosinophilic nucleolus and scattered mitotic figures. Desmoplasia is absent or minimal.
  • consultation
    • 2022-08-25 ENT
      • Q
        • This 59-year-old man with past history of
          • Nasopharyngeal carcinoma, cT1N3bM0, stage IVB s/p CCRT and adjuvant chemotherapy with PF on 2017; Recurrence nasopharyngeal carcinoma over subcutaneous tissue of lower neck, rcT0N0M1, stage IVC, s/p CCRT on 2022/03/18 and adjuvant chemotherapy with PF three times again since 2022/04~2022/06.
          • Lymphoepithelial carcinoma of Right parotid with peri-salivary gland tissue invasion, pT3cN0M0, s/p parotidectomy with positive and CCRT on 2021/04~2021/07
          • Hypothyroidism under thyroxin control.
        • This time, he had face/neck and chest wall swelling, orthopnea (cough at night), distended neck veins, collateral circulation, swelling over bilateral axillas and dyspnea for several weeks.
        • Under the impression of SVC syndrome, he is admitted to our ward for further evaluation and management.
        • 20220817 Chest CT:
          • Occlusion of Rt IJV, subclavian and innominate vein, with pleural effusion
          • Bony metastasis and suspect metastatic LNs in axillary regions and mediastinum
        • S
          • He was regularly followed up at your ward, and he would arrange to follow your ward again on 20220822.
          • He had done right axillary LN dissection on 20220824. He was found the foreign on his throat, when he was inbutation for operation.
          • He also complained that he was hard to swollen in recent several days.
        • We would like to consult your expertise for recurrent NPC further evaluation and management. Thanks in advance and have a nice day.
      • A
        • SOB after intubation.
        • Scope:
          • Nasopharynx: smooth
          • Larynx and hypopharynx: epiglottis and bi arytenoid and bi false cord edema, airway small but adequate
        • Imp: Supraglottic edema, suspected RT and intubation trauma related
        • Plan:
          • IV steroid for 5-7 days, monitor airway
    • 2022-08-19 General and Gastrointestinal Surgery
      • Q
        • We would like to consult your expertise for his axillary LN biopsy further evaluation and management.
      • A
        • Due to suspected that bilateral axillary LN metastasis and related SVC syndrome. Axillary LN biopsy is consulted.
        • O:
          • vital signs: stable, no fever
          • PE: no central vein stenosis
          • lab data: see chart
        • A: suspected that bilateral axillary LN metastasis
        • P: I will arrange axillary LN biopsy, R’t on 20220824
  • surgical operation
    • 2022-01-26
      • Surgery
        • Lower neck and chest wall mass incisinal biopsy        
      • Finding
        • Lower neck and chest wall swelling and induration
    • 2021-04-21
      • Surgery
        • Parotidectomy. right
      • Finding
        • Several indurated nodules over right parotid gland
        • Sacrificed of right greater auricular nerve
    • 2020-12-24
      • Surgery
        • total excision
      • Finding
        • skin tumor
  • radiotherapy
    • 2022-08-25 ~ 2022-09-05 - 2100cGy/7 fractions (6 MV photon) to low pelvis & hips.
    • 2022-03-16 ~ 2022-03-18 - boost 1050cGy/3 fractions to lower neck and pre-sternal soft tissue tumor due to slow regression
    • 2022-02-15 ~ 2022-03-15 - 6000cGy/20 fractions (6 MV photon) to lower neck and pre-sternal soft tissue tumor
    • 2021-05-24 ~ 2021-07-05 - 6000cGy/30 fractions (6 MV photon) to Rt parotid bed and regional lymphatics
    • 2017-03-08 ~ 2017-04-26 - 7140cGy/34 fractions (6 MV photon) to NPX & neck LAPs
      • Cisplatin: 2017-03-10, 2017-03-16, 2017-03-23, 2017-03-30, 2017-04-06, 2017-04-13, 2017-04-20, 2017-04-24.
      • Radiation mucositis, grade 2; pharyngitis, grade 2; dermatitis, grade 2; N/V, grade 0; esophagitis, grade 1.
  • chemoimmunotherapy
    • 2022-08-31 - cisplatin 80mg/m2 130mg 2hr D1 + gamcitabine 1250mg/m2 2100mg 30min D1
    • 2022-06-10 - cisplatin 80mg/m2 140mg 3hr D1 + fluorouracil 1000mg/m2 1790mg 24hr D1-4 (PF Q4W)
    • 2022-05-06 - cisplatin 80mg/m2 140mg 3hr D1 + fluorouracil 1000mg/m2 1790mg 24hr D1-4 (PF Q4W)
    • 2022-04-07 - cisplatin 80mg/m2 140mg 3hr D1 + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF Q4W)
    • 2022-03-16 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2022-03-09 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2022-03-02 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2022-02-23 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2022-02-16 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2021-06-30 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2021-06-23 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2021-06-16 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2021-06-09 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2021-06-02 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)
    • 2021-05-26 - cisplatin 30mg/m2 50mg 2hr D1 (cisplatin weekly, CCRT)

[assessment, not posted]

  • An elevated level of D-dimer has been observed.
    • 2022-09-12 D-dimer 3998.90 ng/mL(FEU)
    • 2022-09-07 D-dimer 2014.01 ng/mL(FEU)
    • 2022-08-26 D-dimer 2846.63 ng/mL(FEU)
    • 2022-08-23 D-dimer 3582.31 ng/mL(FEU)
    • 2022-08-19 D-dimer 4672.59 ng/mL(FEU)
  • In patients with VTE and cancer (cancer associated thrombosis [CAT]) there is a higher risk for recurrence as well as a higher risk for major bleeding than in patients with VTE without cancer. Because DOACs have not been compared head-to-head among patients with cancer, apixaban or LMWH may be the preferred option in patients with luminal GI malignancies who place higher value on avoiding GI major bleeding, whereas others may elect the convenience of oncedaily DOAC therapy (edoxaban or rivaroxaban). However, LMWH has the potential advantages of bypassing the GI system in patients with nausea or mucositis and may be more easily dose-adjusted in patients with thrombocytopenia due to cancer therapy.
  • Eliquis (apixaban) has been introduced since 2022-09-01. (Superior Vena Cava Syndrome suspected? 2022-08-17 CT).

701346860

220907

[objective]

  • past history
    • DM(-), HTN(-)
    • Arrhythmia/tachycardia s/p ablative surgery at WanFang Hospital
    • Facial herpes zoster reactivation s/p medical therapy neurotin and methylcobalamin
    • Appendectomy and neck mass excision 40 years ago
  • lab data
    • 2021-12-30 Anti-HBs 254.35 mIU/mL
    • 2021-12-30 Anti-HBc Reactive
    • 2021-12-30 Anti-HBc-Value 4.38 S/CO
    • 2021-12-30 HBsAg Nonreactive
    • 2021-12-30 HBsAg (Value) 0.68 S/CO
    • 2021-12-30 Anti-HCV Nonreactive
    • 2021-12-30 Anti-HCV Value 0.05 S/CO
  • exam finding
    • 2022-07-15 CT - abdomen, pelvis
      • History: Endometrium serous adenocarcinoma, high grade, T1N0M0, stage I s/p Staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 2021/12/22 s/p concurrent chemoradiotherapy
      • Findings:
          1. S/P hysterectomy.
          1. Disc space narrowing at L5/S1.
          • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P hysterectomy. There is no evidence of tumor recurrence.
    • 2022-02-24 Hearing Test
      • PTA, Pure-tone Audiometry
        • Reliability FAIR
        • Average R’t 23 dB HL // L’t 21 dB HL
        • Bil normal to moderately severe SNHL
    • 2022-01-27 KUB
      • Diffuse bowel dilatation with barium retention. Stationary.
    • 2022-01-21 KUB
      • Diffuse small bowel dilatation.
      • Retention of barium in the bowel loops.
    • 2022-01-19 Small intestine
      • Small bowel ileus.
      • The passage time is more than 24 hours.
    • 2022-01-02 CT - abdomen, pelvis
      • S/P hysterectomy. Small bowel ileus and the transtitional zone.
      • Distention of stomach.
    • 2022-01-02 EKG
      • Sinus rhythm with short PR
      • Nonspecific ST abnormality
    • 2021-12-22 Patho - uterus (with or without SO) neoplastic
      • Pathologic diagnosis
        • Uterus, endometrium, staging surgery — Serous carcinoma, high-grade
        • Uterus, myometrium, total hysterectomy
          • — Involved by serous carcinoma (< 1/2 thickness)
          • — Intramural myoma
        • Uterus, cervix, total hysterectomy
          • — Endocervix involved by tumor
          • — Cervical stromal not involvement
          • — Free of cervical margin
        • AJCC 8th edition Pathology stage: pT1aN0(if cM0); FIGO IA; AJCC stage IA
      • Microscopic Examination
        • Histology type: Serous carcinoma
        • Histology grade: High-grade
        • Depth of invasion: 2 mm (invade <1/2 thickness of the myometrial wall)
    • 2021-12-10 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, EM sampling — serous adenocarcinoma, high grade
      • IHC stains: p53 (aberrant type), WT-1 (+), CK20 (-), PAX-8 (-), ER (-, 0%), PR (-, 0%).
    • 2021-12-09 Gynecologic ultrasonography
      • Endometrial hyperplasia(EM:30.1mm), suspected endometrial malignancy
      • thickness of the posterior wall: 0.47cm
  • consultation
    • 2022-01-20 General and Gastrointestinal Surgery
      • Q
        • This is a 71 y/o female, G5P3AA2 (NSD*3) with the past history of cardiac arrhythmia s/p ablative surgery. She is just discharged from our hospital due to endometrial cancer pT1aN0(if cM0); FIGO IA s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 2021/12/22 and subsequently admitted again due to post-operative ileus. However, she suffered from abdominal fullness since yesterday morning and had colicky abdominal pain. She recalled only eating pumpkin porridge yesterday morning. She vomited once this early morning at 2AM. She denied diarrhea, fever, coffee ground or bloody emesis. Because of the severe discomfort, she was brought to our ER. At the ER, KUB showed presence of ileus. Thus, primperan was given and she was kept on NPO. Due to the above problem, she is admitted for further management and close observation.
        • Abdominal to pelvis CT showed S/P hysterectomy. Small bowel ileus and the transtitional zone. Distention of stomach. As a result, we need your help and expertise for assessment and management of her ileus.
      • A
        • Assessment
          • Ms. Chen had been found with postoperative intestinal obstruction. Small bowel series disclosed small bowel obstructin.
        • Suggestion
          • Please keep NPO, iv fluid, and maybe NG decompression if vomiting
          • F/u KUB subsequently
          • Surgical intervention is preserved only if peritonitis or failed conservative treatment.
    • 2022-01-05 General and Gastrointestinal Surgery
      • Q
        • This is a 71 y/o female, G5P3AA2 (NSD*3) with the past history of cardiac arrhythmia s/p ablative surgery. This time, she is just discharged from our hospital due to endometrial cancer pT1aN0(if cM0); FIGO IA s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 2021/12/22. However, she suffered from abdominal fullness last night and felt nausea but did not vomit. She recalled only eating steamed bun and vegetables. Because of the severe discomfort, she was brought to our ER. At the ER, KUB showed presence of ileus. Blood exam showed mildly elevated WBC 11K, band form 1.9%, CRP 0.42. Empiric antbiotics of Brosym was given. Abdominal CT showed S/P small bowel ileus and distention of stomach. Thus, NG decompression (2150/day), dulcolax 1# prnq4h and primperan was given and she was kept on NPO use. Due to the above problem, she is admitted for further management and close observation.
      • A
        • Assessment
          • Mrs. Chen had received operation and discharged recently. However, intestinal obstruction is suspicious. PE showed soft palpation.
        • Suggestion
          • Please keep current treatment and f/u KUB subsequently
          • Conservative treatment at first
    • 2021-12-31 Radiation Oncology
      • S:
        • For postoperative radiotherapy due to serous carcinoma of the uterine endometrium.
        • PI: This 71-year-old woman, G5P3AA2, menopausal at 50 years old. She had history of cardiac arrhythmia s/p ablative surgery. MRI of pelvis (2021-12-13) showed lobulated tumor, 5.8cm in the uterine cavity (body), suspected endometrial malignancy . She then noted fresh red vaginal spotting again on 2021/12/17. She underwent staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection) on 12/22/2021.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Allergy(-)
        • Travel hx(-)
        • Other disease: heart disease
        • Previous RT Hx: (-)
      • O:
        • ECOG: 0
        • PE: neck and bil SCF: neg; abdomen: a longitudinal surgical scar; bil low limbs: no edema.
        • MRI of pelvis (2021-12-13): Lobulated tumor, 5.8cm in the uterine cavity (body), suspected endometrial malignancy. Unremarkable change of the liver, spleen, pancreas and both kidneys. No enlarged lymph node in the paraaortic region. Minimal ascites in the pelvic cavity. Bulging disc at L5-S1. Impression: Lobulated tumor in the uterus, suspected endometrial malignancy. If proven malignancy, T1N0M0. Post-op proven endometrial malignancy.
        • CXR (2021-12-21): No active lung lesion. No cardiomegaly.
        • Operation (2021-12-22): Staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection)
        • Ascites (N2021-04522, 2021-12-23): neg.
        • Pathology (S2021-19117, 2021-12-28):
          • Uterus, endometrium, staging surgery — Serous carcinoma, high-grade.
          • Uterus, myometrium, total hysterectomy — Involved by serous carcinoma (<1/2 thickness) — Intramural myoma.
          • Uterus, cervix, total hysterectomy — Endocervix involved by tumor — Cervical stromal not involvement — Free of cervical margin.
          • AJCC 8th edition Pathology stage: pT1aN0(if cM0); FIGO IA; AJCC stage IA.
          • Lymphovascular Invasion: Present
        • CXR (2021-12-31): No active lung lesion. Normal heart size and contour. S/P port-A insertion via left subclavian vein.
      • A:
        • Serous carcinoma, high-grade, of the uterine endometrium, AJCC 8th edition Pathology stage: pT1aN0(cM0); FIGO IA; AJCC stage IA, s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection).
      • P: Systemic therapy and vaginal brachytherapy is indicated for this patient with the following indicators: serous carcinoma, high-grade, of the uterine endometrium, stage: pT1aN0(cM0); FIGO IA
        • Goal: curative
        • Treatment target and volume: vaginal cuff mucosa surface
        • Technique: IVRT
        • Preliminary planning dose: 600cGy to vaginal cuff mucosa surface x 5 fractions by IVRT.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-1-21.
    • 2021-12-31 Hemato-Oncology
      • this 71 year old woman is a case of endometrium serous adenocarcinoma, high grade, pstageIA.
      • for invasive stageIA case, systemic therapy is indicated.
      • we will discuss with patient for systemic chemotherapy (self pay palitaxel 175mg/m2 + self pay carboplatin AUC target 6) Q3W.
      • arrange our OPD after discharge.
  • surgical operation
    • 2021-12-22 Staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + paraaortic lyphnode dissection)
  • radiotherapy
    • 2022-02-22 ~ 2022-04-12 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa area by IVRT.
  • chemoimmunotherapy
    • 2022-09-06 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
    • 2022-08-16 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
    • 2022-07-14 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
    • 2022-06-24 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr
    • 2022-06-07 - paclitaxel 175mg/m2 210mg 3hr + carboplatin AUC 5 300mg 2hr (paclitaxel 240mg -> 210mg for leukocytopenia)
    • 2022-04-25 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 300mg 2hr
    • 2022-03-30 - cisplatin 40mg/m2 60mg 3hr (CCRT)
    • 2022-03-23 - cisplatin 40mg/m2 60mg 3hr (CCRT)
    • 2022-03-16 - cisplatin 40mg/m2 60mg 3hr (CCRT)
    • 2022-03-09 - cisplatin 40mg/m2 60mg 3hr (CCRT)
    • 2022-03-02 - cisplatin 40mg/m2 60mg 3hr (CCRT)
    • 2022-02-24 - cisplatin 40mg/m2 55mg 3hr (CCRT)

==========

2022-09-07

  • Leukocytopenia is anticipated to be mitigated as a result of reducing the dosage of Paclitaxel and adding G-CSF.

2022-08-17

  • There is no evidence of tumor recurrence found by 2022-07-15 CT.

2022-06-08

  • According to lab results on 2022-06-02, WBC, RBC, and HGB were slightly lower, however this should not affect the chemotherapy.
  • The D-dimer reading gradually decreased to near normal levels, which might be considered as a good sign
    • 2022-05-30 674.30 ng/mL(FEU)
    • 2022-05-05 774.52 ng/mL(FEU)
    • 2022-02-22 907.50 ng/mL(FEU)
    • 2022-02-15 1010.02 ng/mL(FEU)
    • 2022-01-21 1793.51 ng/mL(FEU)
    • 2022-01-08 3883.44 ng/mL(FEU)
  • Chronic viral hepatitis B as well as constipation are currently treated with Baraclude (entecavir) and magnesium oxide, respectively.
  • BP 141/68 (2022-06-07 15:50) -> 102/58 (2022-06-07 20:48), please keep track of its drop rate.

2022-04-26

  • The patient has endometrial serous carcinoma of high grade, s/p surgery on 2021-12-22, and CCRT during late February to the end of March in 2022. She has been administered paclitaxel + carboplatin as of this hospital stay.
  • The CBC and WBC results reported on 2022-04-20 and liver and kidney function, serum electrolytes reported on 2022-04-13 were grossly normal. Chronic viral hepatitis B is managed with Baraclude (entecavir) 0.5mg QDAC.
  • For those with human epidermal growth factor receptor 2-overexpressing (HER2 data not found yet), addition of trastuzumab to current chemotherapy might be considered optionally.

700513871

220906

  • exam finding
    • 2022-08-18 Fluid cytology - dialysate
      • after IP: 10cc, yellow, turbid
      • Smears show neutrophils, lymphocytes, and atypical, pleomorphic hyperchromatic cells.
      • Malignancy is favored.
    • 2022-08-15 Fluid cytology - dialysate
      • before IP: 13 cc, light-yellow, clear
      • Smears show necrotic debris, neutrophils, lymphocytes, and clusters of pleomorphic cells.
      • Malignancy is favored.
    • 2022-08-12 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-05-23 Fluid cytology - ascites
      • after IP C/T: adenocarcinoma, degenerated;
      • Many lymphocytes, mesothelial cells, and few degenerated adenocarcinoma cells present.
    • 2022-05-16 Patho - peritoneum biopsy
      • Peritoneum tumor, laparoscopic excision — Metastatic poorly-differentiated carcinoma
      • Microscopically, the sections shows a poorly-preserved specimen with almost crush artifact and only a few pleomorphic, patternless, well-preserved tumor cells, which immunohistochemistry of CK(-), PAX-8(+, focal), WT-1(-, cytoplasmic staining) and P53 does not have aberrant expression. However, PAX-8 IHC stain is mainly used for renal carcinoma, thyroid carcinoma and gynecologic carcinoma. According to radiologic findings, metastatic poorly-differentiated carcinoma with gynecologic origin should be first considered. Clinical correlation is advised.
    • 2022-05-11 Flow volume loop
      • moderate restrictive impairment
    • 2022-05-11 2D transthoracic echocardiography
        1. Sub-optimal echo window
        1. Normal AV with mild AR
        1. Normal MV with no MR
        1. Concentric LVH
        1. Preserved LV and RV systolic function
        1. Mild PR, mild TR, normal IVC size
    • 2022-05-10 Whole body PET scan
        1. A focal area of increased FDG uptake in the midline lower pelvic region about uterus. Malignancy of the uterus should be watched out. Please correlate with other clinical findings for further evaluation.
        1. Multiple glucose hypermetabolic lesions in the abdominal and pelvic cavities and a glucose hypermetabolic lesion in the midline anterior lower abdominal wall, compatible with multiple metastatic lesions. Please also correlate with other clinical findings for further evaluation.
    • 2022-05-09 Cell block
      • Peritoneal carcinomatosis with ascites.
      • The smears and cell block show lymphocytes, reactive mesothelial cells and some pleomorphic atypical cell clusters, suggestive of malignancy, but uncertain origin due to limited ICC stains. Immunocytochemistry shows PAX-8(-), WT-1(-, cytoplasmic staining), ER(-), CD10(-) and P53(+) for pleomorphic cell. Confirmatory biopsy is advised for further evaluation.
    • 2022-05-09 Gynecologic ultrasonography
        1. Suspected Ascites:(+)
        1. Endometrial thickening.(Em:2.14), endometrial (+fluid)
        1. Suspected endometrial mass
    • 2022-05-06 Patho - esophageal biopsy
      • Esophagus, 23cm below incisors, s/p biopsy — benign squamous mucosa with abundant granular cytoplasm, suggestive of glycogenosis.
    • 2022-05-06 Patho - colorectal polyp
      • Colon, descending colon, post Biopsy removal — Hyperplastic polyp
    • 2022-05-05 CT - liver, spleen, biliary duct, pancreas
      • Peritoneal carcinomatosis with ascites.
    • 2022-05-04 Fluid cytology - ascites
      • Smears show atypical hyperchromatic and pleomorphic tumor cells.
      • Malignancy is favored. Please correlate with the clinical presentation.
    • 2022-05-03 SONO - abdomen
      • Diagnosis
          1. Parenchymal liver diseae
          1. Ascites, moderate amount
          1. Hepatic cyst
      • Suggestion
        • abdominal paracentesis
    • 2018-03-31 CT - abdomen
      • Right UVJ stone (4.5mm) with obstructive uropathy. Right renal stones (2-4mm).
  • consultation
    • 2022-05-20 Hemato-Oncology
      • Q
        • for neoadjuvant chemotherapy with IP + systemic
        • This 77 y/o female patient has the history of hypertension. This time, due to mild epigastric pain and abdominal fullness were noted. Abdominal sonography was done that showed ascites. Abdominal paracentesis was done and the analysis showed exudate; abdominal sonography showed 1.Prob. Liver cirrhosis 2.Ascites, moderate amount 3.hepatic cyst.
        • Abdominal CT showed Peritoneal carcinomatosis with ascites. Ascites cytology showed Smears show atypical hyperchromatic and pleomorphic tumor cells. Malignancy is favored. Further whole body PET was performed and showed 1) A focal area of increased FDG uptake in the midline lower pelvic region about uterus. Malignancy of the uterus should be watched out. Please correlate with other clinical findings for further evaluation. 2) Multiple glucose hypermetabolic lesions in the abdominal and pelvic cavities and a glucose hypermetabolic lesion in the midline anterior lower abdominal wall, compatible with multiple metastatic lesions. Please also correlate with other clinical findings for further evaluation.
        • Laparoscopic exam was performed on 20220516 and operation finding showed peritoneal carinomatosis including 4 quadrant and small bowel mesentry. PCI: 13/39. laparoscope intraabdominal tumor excision with biopsy was performed and pathology pending. We need your help for further management for neoadjuvant IP + systemic chemotherapy. Thanks for your time!!
      • A
        • Impression:
            1. Peritoneal carcinomatosis and malignant ascites, origin unkown, s/p laparoscope intraabdominal tumor excision, PD tube inserted and Port-A insert on 20220516
            1. HTN
        • Suggestion:
            1. Keep best supportive care and nutrition support.
            1. Pending pathology result. We will discuss with patient about further neoadjuvant IP + systemic chemotherapy.
            1. Thanks for your consultation. We wound like to follow up this case. If there is any problem, please feel free to let us known.
    • 2022-05-09 Obstetrics and Gynecology
      • Q
        • Tumor maker with CA 125 showed 476.8 U/ml. So we need you evaluation and suggestion of this patient.
      • A
        • S
          • 77 y/o, female, G2P2(C/S)
          • Hx: Admitted due to abdominal fullness
        • O:
          • CA125: 485
          • sono: uterus: AVF: 57x37mm, endometrial mass 20x19mm, EM:21.4mm
          • bilaterla adnexa free
          • Abdominal CT showed Peritoneal carcinomatosis with ascites.
          • Ascites cytology showed Smears show atypical hyperchromatic and pleomorphic tumor cells.
        • IMP:
          • Peritoneal carcinomatosis and malignant ascites, origin unknown
        • P:
          • Please informed us the result of cell block
    • 2022-05-06 Obstetrics and Gynecology
      • A
        • CT of pelvis/abdomen report not mention about GYN lesion
        • no adnexa mass; UT : myoma?
        • might check CEA/CA125/CA199 first
        • suggest ascites sent for cell block to check the origin of malignancy
        • Please connect us, if GYN origin likely by cell block, thank you.
  • chemoimmunotherapy
    • 2022-09-06 - paclitaxel 50mg/m2 80mg IVD 3hr + carboplatin AUC 2 100mg IVD 2hr + docetaxel 30mg/m2 40mg IP 1hr + carboplatin 100mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP
    • 2022-08-16 - paclitaxel 50mg/m2 87mg IVD 3hr + carboplatin AUC 2 100mg IVD 2hr + decetaxel 30mg/m2 40mg IP 1hr + carboplatin 100mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP
    • 2022-06-17 - paclitaxel 50mg/m2 87mg IVD 3hr + carboplatin AUC 2 100mg IVD 2hr + decetaxel 30mg/m2 40mg IP 1hr + carboplatin 100mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP
    • 2022-05-19 - paclitaxel 50mg/m2 87mg IVD 3hr + carboplatin AUC 2 120mg IVD 2hr + decetaxel 30mg/m2 40mg IP 1hr + carboplatin 120mg IP 1hr + gentamicin 40mg IP + NaHCO3 70mg/mL 40mL IP

==========

2022-09-06

  • 2022-09-05 creatinine 2.62, CrCl 15mL/min, eGFR 18.8.
  • febuxostat for patient with CrCl <30 mL/minute: Initial: 20 to 40 mg once daily (manufacturer’s labeling; expert opinion). Observational studies in patients with hyperuricemia have reported safety and tolerability of 60 and 80 mg/day; a careful titration may be considered in patients unresponsive to standard doses. The recommended dose is 0.5# (40mg) QD if no other clinical considerations exist.
  • entecavir for patient with CrCl 10 to <30 mL/minute: Administer 30% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 72 hours. There is no urgent need to adjust the dosage of Baraclude as it is currently prescribed as 0.5mg 1# QOD.
  • furosemide for patient with eGFR <=30 mL/minute/1.73m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >160 to 200 mg IV (or oral equivalent) are unlikely to result in additional diuretic effect

2022-08-15

  • As a result of renal impairment, drug doses have been adjusted. There is no issue with active prescription.

700563751

220906

  • diagnosis
    • 2022-09-02 discharge
      • 1: suspect left breast cancer with left axillary LNs and hepatic metastases
      • 2: Dyspnea, unspecified
  • lab data
    • HBV, HCV
      • 2022-09-02 HBsAg (NuMe) Negative
      • 2022-09-02 HBsAg Value (NuMe) 0.443
      • 2022-09-02 Anti-HCV (NuMe) Negative
      • 2022-09-02 Anti-HCV Value (NuMe) 0.0345
      • 2022-09-01 HBsAg Nonreactive
      • 2022-09-01 HBsAg (Value) 0.25 S/CO
      • 2022-09-01 Anti-HCV Nonreactive
      • 2022-09-01 Anti-HCV Value 0.09 S/CO
      • 2022-08-30 Anti-HBc Nonreactive
      • 2022-08-30 Anti-HBc-Value 0.95 S/CO
  • exam finding
    • 2022-09-02 Patho - breast biopsy
      • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (+, 40%, intermediate intensity), PR(-, 0%, ), Her2/neu: positive (score=3+), Ki-67(25 %), CK5/6 (-), p63 (-).
      • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • 2022-09-02 SONO - breast
      • Left breast tumor with diffuse microcalcifications, suspected malignancy, suggest biopsy.
      • Enlarged left axillary lymph nodes, suspected metastatic lymph nodes.
      • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
    • 2022-09-02 Mammography
      • Left breast microcalcifications with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
      • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
    • 2022-09-01 Patho - stomach biopsy
      • Stomach, low body, biopsy — Chronic gastritis, H pylori present
    • 2022-09-01 Esophagogastroduodenoscopy, EGD
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p random biopsy at low body, GC
    • 2022-08-30 CTA - chest
      • indication
        • Dyspnea for 2 wks
      • findings
        • Lung: a suspect ground-glass nodule at posterior RUL (5mm) and a lobular opacity at peripheral of LUL
        • Chest wall and visible lower neck: small and enlarged LNs at Lt axilla. abnormal enhancing mass in left breast. a well-defined Rt thyroid nodule 10mm
        • Visible abdominal contents: mild ascities at RUQ of abdomen. hepatomegaly with ill-defined hypodense lesions in both lobes.
      • impression
        • Lt breast cancer with left axillary LNs and hepatic metastases.
        • no pulmonary embolism.
        • LUL lobular opacity and RUL GGO 5mm, nature to be determined, suggest follow up. (GGO: ground glass opacity)
    • 2022-08-30 ECG
      • Sinus tachycardia
      • Possible Left atrial enlargement
    • 2022-08-30 CXR
      • Atherosclerotic change of aortic arch

[assessment]

  • There is no anti-HBc test result available yet, HBV immune status remains unknown. ( https://med.stanford.edu/content/dam/sm/liver/documents/resources/guides/cdc_pub.pdf )
  • The immunization of susceptible patients should be strongly considered at the time of cancer diagnosis. (ref: Torres HA, etc. Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer. Nat Rev Clin Oncol 2012; 9:156-66; PMID:22271089; http://dx.doi.org/10.1038/nrclinonc.2012.1 )
  • All unvaccinated patients with cancer aged 19 to 59 years and those >=60 years old with risk factors (eg, diabetes mellitus, chronic liver disease, hepatitis C, hemodialysis, and other risk factors) should receive the hepatitis B vaccine. (ref: Murthy N, etc. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(7):229-233. Published 2022 Feb 18. doi:10.15585/mmwr.mm7107a1 ). As with other vaccines, cancer patients may have suboptimal response to the hepatitis B vaccine. Regimens that include doubling the standard antigen dose or administering additional doses may increase response rates but, given the limited data with these alternative regimens, this approach cannot be routinely recommended.

700137025

220905

  • exam finding
    • 2022-09-02 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 28) / 93 = 69.89%
        • Preserved LV and RV systolic function with normal wall motion
        • Grade 1 LV diastolic dysfunction
        • Mild TR and moderate sclerotic AS (TR = tricuspid regurgitation; AS = aortic stenosis)
    • 2022-08-20 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • S/P NG tube placement.
      • Osteopenia of the bony structure is noted.
      • Increased pulmonary vasculature is found.
    • 2022-08-18 Patho - colorectal polyp
      • Intestine, large, hepatic flexure to A-colon, biopsy— signet ring cell carcinoma
      • Microscopically, it shows signet ring cell carcinoma composed of proliferation of malignant tumor cells arranged in solid architecture, and signet-ring cell diffferentiation.
      • Immunohistochemical stain— EGFR(+), MLH1(+), MSH2(+), MSH6(+), PMS2(-)
    • 2022-08-17 Colonoscopy
      • Diagnosis
        • Colon ulcerative mass, hepatic flexure to A-colon, s/p biopsy
        • Pseudopolyps, T-colon
        • Melanosis coli
        • Internal hemorrhoid
      • Suggestion
        • Please pursue pathology report
      • Complication
        • No immediate complication
    • 2022-08-16 Patho - stomach biopsy
      • Stomach, antrum, biopsy — Ulcer with chronic inflammation, H pylori NOT present
    • 2022-08-13 CT - abdomen, pelvis
      • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:4a(T_value) N:1b(N_value) M:____(M_value) STAGE:IIIB(Stage_value)
    • 2022-08-13 CXR
        1. Unremarkable change in the visible trachea
        1. Normal cardiac size; mediastinal widening
        1. Lung markings: small patches in the left upper lung field and right middle lung fields.
        1. Normal bilateral hemidiaphrams
        1. Blunting bilateral costophrenic angles
        1. Unremarkable change in bilateral clavicles
    • 2022-07-26 CT - brain
      • No acute infarct, No ICH. Brain atrophy. Atherosclerosis.
    • 2022-07-26 ECG
      • Normal sinus rhythm
      • Incomplete right bundle branch block
      • Borderline ECG
    • 2022-07-13 Percutaneous transluminal angioplasty, PTA
      • clinical diagnosis:
        • AVF dysfunction
      • Indication
        • The patient was referred with swelling of left arm and left forearm. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
      • Approach
        • Percutaneous access was performed through the av shunt fistula where a 6F sheath was inserted.
      • Procedure
        • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 50cc. The patient was treated with dormicum (Dosage=1.5 mg).
      • Finding Summary
        • Left Radio cephalic AVF, draining axillary vein : 91% stenosis. AV fistula.
        • Left Radio cephalic AVF, draining basilic vein : 75% stenosis. AV fistula.
      • Intervention Summary
        • Left Radio cephalic AVF, draining axillary vein, Pre-DS = 91%
          • MLD/RVD=0.65/7.18 mm → 6.08/7.13 mm, Post-DS = 15%.
          • Guide Wire: Terumo Radifocus 0.035 150cm.
          • Balloon: Boston Mustang. 8.0 X 60 mm. Pressure: 8 atmospheres.
        • Left Radio cephalic AVF, drainig basilic vein, Pre-DS = 75%
          • MLD/RVD=1.69/6.87 mm → 6.31/6.84 mm, Post-DS = 8%.
          • Guide Wire: Terumo Radifocus 0.035 150cm.
          • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 6 atmospheres.
      • In conclusion :
          1. S/P PTA for left radiocephalic AVF, draining axillary vein, successful, from 91% to 15% residual stenosis
          1. S/P PTA for left radiocephalic AVF, draining basilic vein, successful, from 78% to 5% residual stenosis
    • 2022-07-11 MRA - brain
      • Brain atrophy.
    • 2022-07-11 CXR
      • Elevation of both hemidiaphragms
      • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
      • mild enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
      • Clean lung fields based on plain image
      • Costophrenic angles are preserved
      • marginal spurs of multiple vertebral bodies
      • Joint space narrowing at bilateral glenohumeral joints, may be inflammatory arthritis
    • 2022-07-11 CT - brain
      • Brain atrophy. Atherosclerosis.
    • 2022-06-24 Peropheral Vascular Test - AV fistula
      • clinical diagnosis: AVF dysfunction
        1. Access type: Native
        1. Site:Left radiocephalic AVF
        1. Clinical problem: Swelling of left forearm and left arm
        1. Age of vascular access:
        1. Result:
        • The venous Duplex study revealed a left radiocephalic AVF. The cephalic veinw as patent, with aneursymal dilatation at the cannulation sites. The venous diameter at A cannulation site and V cannulation site were 21.5mm and 14.7~10.2mm. Upstream draining basilic vein was patent. Upstream draining cephalic vein at left arm level was patent but with vessel tortousity.
        • The estimated flow volume measuerd at the feeding radial artery was 877 ml/min.
        • The measured MVO/SVC ratio at right amr level was 100%, indicated no significant right central vein stenosis or occlusion.
          • Right side:
            • SVC: 1.3 mmHg ;
            • MVO/SVC: 100 % ;
        • Suggestion:
          • Left central vein stenosis or oclusion is highly suspected according to the physical examination and clinical presentation.
          • IV DSA and PTA prn is recommended. However, her family refused further IV DSA study.
        1. Suggestion: PTA
    • 2022-06-13 CXR
      • Cardiomegaly and tortuosity of the thoracic aorta.
      • Widening of the mediastinum.
      • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
      • Osteopenic change.
    • 2022-03-26 CXR
      • Elevation of both hemidiaphragms may be due to expiratory phase.
      • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
      • mild enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
      • Clean lung fields based on plain image
      • Costophrenic angles are preserved
      • marginal spurs of multiple vertebral bodies
    • 2022-01-08 ECG
      • Sinus rhythm with sinus arrhythmia with occasional Premature ventricular complexes
      • Otherwise normal ECG
    • 2021-12-01 CT - abdomen
      • History and Indication: 89 y/o, 2021/11/29 coming here due that she is told to have abnormal liver fucntion test with elevated ALP & GGT, so request CT study
      • Hx of ESRD on HD since 2007-05-09
      • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
          1. There is asymmetrical wall thickening at distal ascending colon, near hepatic flexure, that may be adenocarcinoma. Please correlate with colonoscopy.
          1. Both kidney show small size and thin parenchyma that are c/w ESRD.
          1. Two small gallstones are noted.
          1. The liver shows mild irregular contour that may be early cirrhosis? please correlate with clinical condition.
          1. Compression fracture of L1 vertebral body. Mild Disc space narrowing with marginal osteophyte formation and vacuum phenomenon from L2 to S1.
          1. Hyperplasia of bilateral adrenal gland are noted.
          1. There is no focal abnormality in the biliary system, pancreas, and spleen.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Adenocarcinoma of the distal ascending colon is suspected. Please correlate with colonoscopy.
    • 2021-10-22 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • GB polyps
        • C/W ESRD
        • Fatty infiltration of pancreas
        • Suboptimal exam of liver due to poor echo window
      • Suggestion
        • Please correlate with other image study and clinical condition
        • Regular f/u
    • 2021-05-07 CT - coronary artery calcium socre, without contrast
      • Nonenhanced ECG-gated CT for calcium scoring was obtained using 64-slice multidetector row CT scanner showed:
          1. Calcification of the coronary arteries. (LAD=17, LCX=4, RCA=55). Total calcium score=76
          1. Unremarkable of the pericardium.
          1. The heart size is normal. Calcified aortic valve and mitral valve is found.
          1. The visible lung fields are intact.
          1. There is no evidence of mediastinal LAP at visible field.
          1. Patent airway at the examing field.
    • 2021-05-03 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 19) / 73 = 73.97%
        1. Normal LV systolic function with normal wall motion.
        1. Concentric LVH; LV diastolic dysfunction Gr 1.
        1. Normal RV systolic function.
        1. Aortic valve calcification with moderate AS (AVA(Doppler) = 1.07 cm² , Mean aortic pressure = 10 mmHg), mild AR; mild MR; mild TR; mild PR
        • Note: Aortic regurgitation (AR); Pulmonary regurgitation (PR); Mitral regurgitation (MR); Tricuspid regurgitation (TR)
    • 2021-02-10 Pure Tone Audiometry, PTA
      • Tymp:
        • R’t perforation; L’t type A.
      • ART:
        • R’t ipsi CNT, contra absent.
        • L’t ipsi absent, contra CNT.
      • PTA
        • Reliability FAIR
        • Average RE 85 dB HL; LE 41 dB HL.
        • R’t moderately severe to profound mixed type HL.
        • L’t mild to moderately severe SNHL.
    • 2021-02-05 CT - brain
      • Brain atrophy. Suspected empty sella.
    • 2021-02-01 Myocardial perfusion SPECT with persantin
        1. Probably normal variant or mild stress-induced ischemia in apical anteroseptal wall, basal inferior wall, and basal inferoseptal wall of LV.
        1. No post-stress dilatation of LV.
    • 2020-10-30 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (51.9 - 14.4) / 51.9 = 72.25%
        1. Eccentric LVH.
        1. Normal RV & LV systolic function. No regional wall motion abnormalities.
        1. Impaired LV relaxation.
        1. Calcified aortic valve, with moderate aortic stenosis (AVA 1.16 cm2).
        1. Mild tricuspid regurgitation.
    • 2019-02-11 Doppler flowmetry - perivasculary
        1. Access type: native
        1. Site: left AVF
        1. Clinical problem: difficult to gain hemostasis
        1. Age of vascular access:
        1. Result:
        • Left radiocephalic fistual with aneurysmal dilatation at arterial and vein cannulation site
        • Vessel size =16-18.4 mm, outflwo cephalic vein at forearm is very tortuous and duplicated ,
        • Vein cannulation site = 10.2-10.9 mm, juxta-area =6.8 mm , only small draining vein at cephalci vein junction
        • Estiamted volume flow from feeding brachial artery =1250-1320 ml/min
        • Adjust needle cannulation site
        1. Suggestion: Clinical follow up
    • 2019-01-02 Bone densitometry - spine
      • L-spines BMD (AP view) performed by DXA revealed:
        • AP L-spines, BMD of L1-4 0.757 gms/cm2, about 2.4 SD below the peak bone mass (74%) and 0.4 SD above the mean of age-matched people (110%).
        • Other detailed data described in the attached reports.
      • IMP: osteopenia
    • 2018-02-14 Doppler color flow mapping, M-mode Echo
        1. Normal chamber size
        1. Normal LV and RV contractility
        1. Impaired LV relaxation
        1. Aortic valve calcification with mild AS
  • consultation
    • 2022-09-02 Nephrology
      • Q
        • for H/D QW 2.4.6
        • This 89-year old woman, a patient of A- colon of signet ring cell carcinoma, Immunohistochemical stain — EGFR(+), MLH1(+), MSH2(+), MSH6(+), PMS2(-). She was admitted for staging work-up. We need expertise to evaluate her condition thanks!
      • A
        • We will arrrange HD QW246.
        • Please prescribe EPO 5000U QW4 if Hb <11.
    • 2022-08-18 Oral and Maxillofacial Surgery
      • Q
        • She was admitted for suspect UGIB (Upper Gastrointestinal Bleeding). This time, for loose upper dentures. So we need you evaluation and suggestion of this patient.
      • A
        • For evaluation of mobility of upper bridge
        • Hx:
            1. epilepsy 2. ESRD 3. HCVD 4. Parkinsonism 5. Hypothyroidism.
        • O:
            1. Mibility of 12xx22 was noted.
            1. Poor cooperation was noted.
            1. Poor oral hygiene was noted.
        • A: Periodontitis of tooth 12, 22
        • P:
            1. Explain the current finding to patient
            1. Suggest reevulation of extraction on OPD after her general condition is stable.
    • 2022-08-15 Nephrology
      • Q: Regular HD day 2,4,6 was noted, we need your evaluation and arranged Hemodialysis
      • A: We will arrrange HD QW246. Please prescribe EPO 5000U qW4 if Hb <11.

[assessment]

  • Evista (raloxifene) might decrease the absorption of Eltroxin (levothyroxine). It is recommended to shift Evista from QD to QL or QN. Or monitor for reduced effects of levothyroxine (ie, signs and symptoms of hypothyroidism) and reduced serum concentrations of thyroxine if raloxifene and levothyroxine are concomitantly administered.
  • Takepron (lansoprazole) should not be ground, but soaked in water and tube-fed with small granules.
  • Keppra (levetiracetam) could be administered 500 mg to 1 g every 24 hours (currently 250mg BID in active prescription); a supplemental dose of 250 to 500 mg is recommended post each hemodialysis session (currently HD QW246). (ref: Bahte SK, Hiss M, Lichtinghagen R, Kielstein JT. A missed opportunity - consequences of unknown levetiracepam pharmacokinetics in a peritoneal dialysis patient. BMC Nephrol. 2014;15:49. doi:10.1186/1471-2369-15-49.)
  • Midodrine 2mg QW246 is used to prevent hypotension caused by hemodialysis; the patient’s blood pressure during this hospitalization was essentially acceptable.

700912048

220905

  • exam finding
    • 2022-08-01 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Compatible with sarcomatoid carcinoma with nearly total tumor necrosis
      • The sections show sheets of spindle to polygonal tumor cells with pleomorphic nuclei and nearly total tumor necrosis.
      • IHC shows following features: CK(-), CK7(-), Vimentin(+), Hepatocyte(-) and Arginase-1(-).
    • 2022-07-27 CT - abdomen
      • Findings:
          1. There are several poor enhancing masses on both hepatic lobes and the largest one measuring 7.1 cm in S2/3.
          • HCCs are highly suspected.
          • The differential diagnosis include cholangiocarcinoma.
          • There are filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis?
          1. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
          • A hepatic cyst measuring 1.5 cm in S6 is noted.
          1. S/P cholecystectomy, splenectomy and hysterectomy.
      • Impression:
        • HCCs on both hepatic lobes are highly suspected.
        • The differential diagnosis include cholangiocarcinoma.
        • Biopsy is indicated.
        • There are filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis?
    • 2022-07-25 SONO - abdomen
      • Hepatic tumors, bilateral lobes, suspected HCC
      • Hepatic cyst, right lobe
      • Parenchymal liver disease
      • Main portal vein and splenic vein thrombosis
    • 2022-01-25 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Spondylosis of the T-spine
      • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • 2021-12-16 Polysomnography, PSG
      • Conclusion:
        • RDI: 40.6/hr
          1. Severe obstructive sleep apnea syndrome with moderate desaturation during sleep.
          1. Sleep efficiency: poor
      • Suggestion:
          1. CPAP is indicated for this case, pressure: 9cmH2O
    • 2021-11-07 Polysomnography, PSG
      • Conclusion:
        • RDI: 40.6/hr
          1. Severe obstructive sleep apnea syndrome with moderate desaturation during sleep.
          1. Sleep efficiency: poor
      • Suggestion:
          1. Refer to ENT/OS for upper airway evaluation.
          1. Non-Supine position would be better
          1. Evaluate heart function.
          1. Body weight reduction.
          1. CPAP is indicated for this case
    • 2021-10-29 CXR
      • elongated and tortuosity of thoracic aorta
      • moderate enlarged cardiac silhoutte due to prominent pericardial fat/prominent mediastinal fat pad
    • 2021-03-09 Cardiac Catheterization
      • In conclusion
          1. Patent coronary artery
          1. LVEF 77.5% and LVEDP 28mmHG, favor diastolic heart failure.
      • Recommendation
        • DC anti-PLT agent.
    • 2021-02-05 Myocardial perfusion SPECT with persantin
        1. Probably moderate to severe myocardial ischemia at the anteroapical wall and anteroseptal wall.
        1. Mild reverse redistribution of radioactivity to the lateral wall, either normal variant or myocardial ischemia may show this picture.
    • 2021-01-21 2D transthoracic echocardiography
        1. Adequate LV systolic function with normal resting wall motion
        1. Dilated LA, concentric LVH; diastolic dysfunction, Gr 1
        1. Trivial MR, trivial TR and trivial PR
        1. Mild pulmonary hypertension
        1. Preserved RV systolic function
    • 2021-01-19 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Negative for malignancy or dysplasia.
      • IHC stains: CD117: 1%, CD34: 1%. MPO: 40-50%, CD61: 2-5%; CD71: 25-30%.
    • 2019-09-16 SONO - abdomen
      • poor echo window: please see discription
      • fatty liver, moderate (incomplete exam of liver)
      • poor visualization of pancreas/spleen/ vessels
      • GB sac not seen
    • 2019-08-13 SONO - abdomen
      • Fatty liver, mild
      • Hepatic cyst
      • Invisible GB
      • Pleural effusion, left
      • Minimal left subphrenic fluid collection, post drainage
      • Pancreas not shown
    • 2019-08-07 CT - abdomen
      • Left pleural effusion with adjacent lung collapse.
      • S/P splenectomy.
      • An encapsulated fluid collection (5.8x9.7cm) at left subphrenic region.
    • 2019-08-06 Echo for abdomen
      • Fatty liver, mild
      • Fluid collection, LUQ of abdomen
      • Pleural effusion, left
      • Hepatic cyst
      • Postcholecystectomy
    • 2019-08-06 Doppler color flow mapping, M-mode Echo
      • Septal hypertrophy. Dilated LA.
      • Normal RV & LV systolic function. No regional wall motion abnormalities.
      • Impaired LV relaxation.
      • Mild mitral regurgitation.
      • Mild tricuspid regurgitation.
    • 2019-05-17 Surgical Pathology Level IV
      • clinical diagnosis
        • Splenomegaly; Thrombocytopenia, unspecified; Unspecified endocrine disorder; Corticoadrenal insufficiency;
      • pathologic diagnosis
        • Bone marrow, biopsy— negative for malignancy
      • Microscopically, it shows normal cellularity (50%), 2:1 of M:E ration, mature trilineage compnents and presence of occasional megakaryocytes.
      • Immunohistochemical stain reveals CD34(-), CD117(-), MPO(+), CD61(focal+) and CD71(+).
    • 2018-09-28 Surgical Pathology Level III
      • clinical diagnosis
        • Caculus of gallbladder with acute cholecystitis without mention of obstruction;
      • pathologic diagnosis
        • Gallbladder, laparoscopic cholecystectomy —- Chronic cholecystitis and cholelithiasis
      • Section shows gallbladder mucosal tissue with invaginated sinus mucosa, marked chronic inflammation and pigmented stone fragments.
    • 2018-07-23 Multiple Sleep Test
      • diagnosis
        • mild OSAS (AHI 14)
      • suggest
        • lateral posture during sleeping
        • body weight reduction
        • f/u PSG one year later
    • 2018-06-21 H Reflex
      • Comments
        • MNCV: normal
        • SNCVL normal
        • F-wave: normal
        • H-reflex: normal.
      • Conclusion
        • This is a normal lowerl limb NCV study.
        • Please correlate with clinical features.
    • 2018-05-29 Sialoscintigraphy
      • Impression
          1. Normal uptake function of bilateral parotid glands and impaired uptake function of bilateral submandibular glands.
          1. The tracer excretion after acid stimulation was fair to good at four main salivary glands.
      • Comment
        • Salivery gland uptake: normal > 0.25%, 0.2%–0.25% (mild), 0.15% - 0.2% (moderate), 0.1%-0.15% (marked), and <0.1% (severe).
    • 2018-05-24 SONO - abdomen
      • Diagnosis
        • Fatty liver,severe
        • Propable chronic liver parenchymal disorders (Please correlate with liver function test)
        • Suspected GB stone
        • Splenomegaly
        • Suboptimal examination of liver due to poor echo window caused by liver
        • Fatty change
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Part of liver,especially liver dome was diffcult of approach
        • Because of fatty liver change and poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • consultation
    • 2022-08-03 General and Gastrointestinal Surgery
      • Q
        • The 57 y/o woman has IPT s/p sleenectomy and cholangiocarcinoma was diagnosis this time, due to massive thrombosis (CT: filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis.) and protal vein thrombosis, so we need your help for surgical assessment.
      • A
        • S: The 57 y/o woman has IPT /p sleenectomy on 1080725 and cholangiocarcinoma was diagnosis this time, due to massive thrombosis (CT: filling defects in the right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein that may be tumor thrombosis.) and protal vein thrombosis. Surgical intervention is consulted.
        • O: vital signs: stable, no fever
          • abdomen: soft, flat, normal bowe sound, no tenderness
        • A: bilateral liver cholangiocarcinoma with IVC and Portal vein thombosis,
        • P: Surgical intervention is not suggested due to impossible en-bloc resection
    • 2022-07-28 Radiation Oncology
      • Q
        • for arrange CT quiding liver biopsy
        • This is a 57-year-old woman with past medical hostories of: 1) Adrenocortical insufficiency; 2) Hypertensive heart disease with heart failure; 3) Idiopathic Thrombocytopenic Purpura s/p splenectomy; 4) Type 2 DM; 5) COPD; 6) Type 2 DM; 7) Severe obstructive sleep apnea syndrome with moderate desaturation during sleep.
        • She regular at chest/CV/Meta/Oncology OPD follow up.
        • This time, she suffered from poor appetite, body weight loss about 10Kg/6 months. She visited to our Chest OPD regular follow up. Blood test was done that showed abnormal liver functions. She was refer to our GI OPD for management. At GI OPD, hepatitis markers with HBsAg, Anti HCV were follow up that showed negative finding. Autoimmune hepatitis profile with IgG, ANA, ASMA, AMA, IgG4 that showed ANA 1:160. Abdominal sonography was performed which revealed hepatic tumors, bilateral lobes, suspected HCC; hepatic cyst, right lobe; parenchymal liver disease and main portal vein and splenic vein thrombosis. Explained this condition to herself, she understood. Under the impression of Suspect HCC. She was admitted to our GI ward for management and further survey.
        • Now, due to abdominal CT showed suspect HCCs on both hepatic lobes with right atrium, IVC, left hepatic vein, both lobes and main trunk portal vein, splenic vein, and superior mesenteric vein thrombosis. The differential diagnosis include cholangiocarcinoma.
        • We need your further survey for liver biopsy.
      • A
        • According to the clinical condition and imaging findings, biopsy is indicated.
    • 2022-07-28 Dermatology
      • Q
        • After admission, she complained about severe lower legs redness (LMD diagnosis: Vasculitis) but now symptoms intensify. Now, we need your further survey. Thanks a lot!!!
      • A
        • This patient suffered from brownish patches on bil legs for months.
        • Imp: Stasis Dermatitis
        • Suggestion:
            1. Sinpharderma 1 tube/bid
            1. Topsym cream 4 tubes/bid

==========

2022-08-04

  • Patients with acute portal vein thrombosis should be started on low molecular weight heparin to achieve rapid anticoagulation, with a switch to an oral anticoagulant (warfarin or possibly a direct-acting oral anticoagulant [DOAC]) once the patient’s condition has stabilized and no invasive procedures are planned.

  • Patients with chronic portal vein thrombosis when treated with anticoagulation, enoxaparin is more often used rather than warfarin because of its shorter duration of action, less variability in anticoagulation, decreased need for monitoring, and decreased difficulty when managing patients around the time of liver transplantation. An alternative is to use an oral anticoagulant.

  • If warfarin is used, goal INR can be set as 2 to 3. (2022-08-03 INR 1.24)

  • Enoxaparin (in active prescription now) used for venous thromboembolism treatment in patients with active cancer:

    • Months 1 to 6: SUBQ: Initial: 1 mg/kg every 12 hours (this patient is 80 kgw => 80mg Q12H) or 1.5 mg/kg once daily (120mg QD; now 60mg Q12H in active prescription) for a total duration of 3 to 6 months. Twice-daily dosing may be more efficacious than once-daily dosing based on post hoc data (60mg Q12H is better than 120mg QD).
    • Maintenance beyond 6 months: considering continuing anticoagulation beyond 6 months in select patients due to the persistent high risk of recurrence in those with active cancer; consider risk versus benefit of bleeding and recurrence.
    • No issue with active prescription.
  • Direct oral anticoagulant (DOAC) therapy is an alternative to enoxaparin or warfarin for treating chronic portal vein thrombosis.

    • The patient has good renal function (2022-08-03 Cre 0.53, eGFR 126), so, except for edoxaban (CrCl >95 mL/minute: edoxaban use is not recommended due to increased risk of ischemic stroke compared to warfarin), any of dabigatran, rivaroxaban, apixaban, or betrixaban might be a candidate for treatment.
    • In the case of Child-Pugh B or C, both rivaroxaban and betrixaban are contraindicated, so dabigatran or apixaban might be a better alternative, even if the patient has a slightly deteriorated liver function. (reference: https://www.ahajournals.org/doi/10.1161/JAHA.120.017559 )
    • Dabigatran has not been studied in patients with active cancer (ACCP [Stevens 2021]; ASCO [Key 2020]).
    • Apixaban might be used in patients with active cancer (eg, metastatic disease or receiving chemotherapy) (ACCP [Stevens 2021]; Agnelli 2020; Leader 2020; McBane 2019).
  • Apixaban oral 10 mg twice daily for certain duration followed by 5 mg twice daily.

    • Optimal duration of therapy is unknown and is dependent on many factors, such as presence of provoking events, patient risk factors for recurrence and bleeding, and individual preferences.
    • Provoked venous thromboembolism: 3 months (provided provoking risk factor is no longer present).
    • Unprovoked venous thromboembolism or provoked venous thromboembolism with a persistent risk factor: >=3 months depending on risk of venous thromboembolism (VTE) recurrence and bleeding.
    • All patients receiving indefinite therapeutic anticoagulation with no specified stop date should be reassessed at periodic intervals.

701269412

220905

  • diagnosis
    • 2022-08-19 discharge
      • 1: Malignant neoplasm of extrahepatic bile duct
      • 2: Cholangitis
      • 3: Obstruction of bile duct
      • 4: Essential (primary) hypertension
      • 5: Enlarged prostate with lower urinary tract symptoms
  • past history
      1. Cholangiocarcinoma T3N2M1, stage IV (Diagnosed on 20220728, Liver and peritoneum mets)
      1. Hypettension
      1. Duodenal ulcer
      1. Nasal cavity benign neoplasm s/p OP
      1. BPH
  • lab data
    • CA199
      • 2022-09-05 CA199 >19090.00 U/mL
      • 2022-07-22 CA199 >19680.00 U/mL
  • exam finding
    • 2022-09-05 SONO - abdomen
      • Diagnosis (Poor echo window, Pancreas and CBD masked by bowel)
        • Parenchymal liver disease
        • Liver tumor (6.89cm and 3.69cm), rigth lobe
        • Dilated bilateral IHD
        • Gallbladder sludge
        • s/p biliary stent.
        • Ascites, moderate
      • Suggestion
        • Please correlated with other image study
    • 2022-09-03 CT - abdomen
      • Indication
        • cholangiocarcinoma with Liver and peritoneum metachest tighness, malnutrition with elevation of bilirubin and ALT level suspected tumor progress and further mets
      • Findings
          1. Progression of mass lesion around gallbladder and CBD. Infiltration lesions in S8 of liver.
          1. Dilation of IHDs. s/p biliary stent.
          1. Progression of peritoneal carcinomatosis.
          1. Progression of ascites.
          1. No bony destructive lesion on these images.
      • Impression
        • c/w cholangiocarcinoma with liver and peritoneum metastasis, in progression;
        • DDx: gallbladder cancer
    • 2022-09-02 Ascites tapping
      • About 3000ml brown asictes was drained.
    • 2022-08-17 CXR
      • Patchy opacity projecting in the right upper lung is suspected. Please correlate with CT.
    • 2022-08-17 Ascites tapping
      • About 3000ml yellow cloudy asictes was drained.
    • 2022-08-15 Body fluid cytology - ascites
      • Smears show lymphocytes, reactive mesothelial cells, and atypical hyperchromatic cells with prominent nucleoli.
      • Malignancy is suspected.
    • 2022-08-12 SONO - abdomen
      • Parenchymal liver disease
      • Liver tumor (0.3cm and 2.7cm), rigth lobe, unknwon etiology.
      • GB tumor
      • Prominent left IHD
      • suspicious, peritoneal carcinomatosis
      • pancreas masked by bowel.
      • Ascites, severe.
    • 2022-08-12 Ascites tapping
      • About 3000ml yellow nontransparent asictes was drained.
    • 2022-08-11 ECG
      • Sinus tachycardia
      • Left axis deviation
      • Septal infarct, age undetermined
    • 2022-08-11 CXR
      • Patchy opacity projecting in the right upper lung is suspected. Please correlate with CT.
    • 2022-07-28 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
      • The sections show a picture of adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present.
      • IHC shows: CK7(+), CK19(+), CK20(-), and Hepatocyte(focal +). The finding is compatible with cholangiocarcinoma.
    • 2022-07-27 Endoscopic ultrasound guided fine needle biopsy, EUS-FNB
      • Suspect gall bladder cancer with biliary obstruction, s/p CH-EUS and EUS FNB
    • 2022-07-25 Endoscopic Retrograde CholangioPancreatography, ERCP
      • After standard sphincterotomy, one plastic biliary stents with Boston Scientific 7 Fr. 12 cm are placed for free drainage.
      • diagnosis: Biliary duct stricture s/p EST & plastic stents (Boston Scientific 7 Fr. 12 cm)
      • suggestion: f/u amylase & lipase
    • 2022-07-23 CT - abdomen
      • indication: Jaundice
      • Imp:
        • Soft tissue mass at distal CBD and cystic duct with obliterating biliary tree with dilated IHDs and CBD, cholangiocarcinoma is favored.
        • Liver mets and diffuse cancerous peritonitis is found. Suggest tissue proof.
      • Imaging Report Form for Cholangiocarcinoma
        • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1(M_value)
    • 2022-07-23 SONO - abdomen
      • Diagnosis
        • GB tumor
        • Bil IHDS & CHD dilatation
        • Parenchymal liver disease
        • Ascites, trivial amount
      • Suggestion
        • CECT study
    • 2022-07-22 CXR
      • Compression fracture of T spine.
    • 2022-07-22 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Abnormal ECG
  • consultation
    • 2022-08-02 Hemato-Oncology
      • Q
        • This 66 year-old male has the histories of 1. Hypettension. 2. Duodenal ulcer. 3. Nasal cavity benign neoplasm post biopsy. He was regullar follow up at GI LMD. He ever came to GI LMD due to body weight lose 6kgs for a year and tea colored urine, clay stool and poor appetite for a week. Blood analysis showed no leukocytosis (9.42*10^3/uL), but left shift (SEG: 80.3 %), elevated hepatobiliary enzyme (AST:148 U/L,ALT:327 U/L, TBI:12.19mg/dl, r-GT:390 U/L,ALP:317 IU/L). HBsAg and Anti-HCV were nonreactive. Abdominal CT was performed on 20220723 and reported cholangiocarcinoma T3N2M1, stage IV. Liver biopsy pathology showed Cholangiocarcinoma. So we need you evaluation and suggestion of this patient. Thank you very much ~
      • A
        • Recommendation:
        • palliative chemotherapy maybe helpful for this patient
        • port-A implantation if patient agree chemotherapy
    • 2022-08-01 Urology
      • Q
        • This time, he sufferred from dysuria. So we need you evaluation and suggestion of this patient. Thank you very much ~
      • A
        • The patient reported urinary frequency with small amount. U/A is clean.
        • He had OAB (overactive bladder, may due to disease or medication realted) and we will prescribed antimuscarinic for him.
        • If symptoms did not improved may contact further evaluation
    • 2022-07-28 Radiation Oncology
      • Q
      • Abdominal CT was performed on 20220723 and reported cholangiocarcinoma T3N2M1, stage IV. We need arrange CT Guide Biopsy of liver, thank you~
      • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • chemoimmunotherapy
    • 2022-08-12 - fluorouracil 1000mg/m2 1500mg 22hr D1-5 + cisplatin 100mg/m2 150mg 3hr D2

701370041

220905

  • exam finding
    • 2022-09-03 CXR
      • Left lower lung infiltrates.
      • Borderline cardiomegaly.
      • Tortuous thoracic aorta with intimal calcification.
      • Thoracic spondylosis.
    • 2022-07-25, -07-21 CXR
      • small Lt pleural effusion and Rt subpulmonary effusion
      • Linear band subsegmental atelectasis at Lt lung base
      • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
      • appropriately positioned gastric tube
    • 2022-07-20 CT - abdomen, pelvis
      • History: bloody stool
      • Findings:
          1. There is segmental circumferrential wall thickening at the sigmoid colon, measuring 5.5 cm in length and 1.6 cm in maximal wall thickness. Adenocarcinoma is highly suspected.
          • In addition, There is a soft tissue mass measuring 4 cm in width at the adjacent mesocolon that may be exophytic tumor or metastatic node?
          1. There is a poor enhancing lesion measuring 5.3 cm in left kidney lower pole with suggestive central soft tissue nodular component that may be cyst or cystic tumor? Please correlate with sonography and contrast-enhanced dynamic CT.
          1. There are bilateral Pleura effusion (more severe on left side) and passive atelectasis in left posterior basal lung.
          1. S/P nasogastric tube insertion
          1. There is mild ascites in right perihepatic space, left para-colic gutter space, and pelvis. please correlate with clinical condition or ascites cytology.
          1. The urinary bladder shows small size, mild wall thickening., gas content and S/P Foley’s catheter insertion.
          1. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4, L4-5 and L5-S1.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3 (T_value) N:N1a (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
    • 2022-07-19 Patho - colon biopsy
      • Colon, 18 cm to 22 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2022-07-19 CXR
      • appropriately positioned gastric tube
      • enlarged cardiac silhoutte
      • mixed crowding of vascular markings and reticular opacities over
      • left lower lung zone?
    • 2022-07-18 Colonoscopy
      • Diagnosis
        • Highly suspected colon cancer, with mild oozing, 18cm to 22cm AAV, s/p biopsy.
        • Internal hemorrhoid
      • Suggestion
        • F/U pathology report
        • CRS consultation
      • Complication
        • No immediate complication
    • 2022-07-13 ECG (ICU)
      • note: low data quality
      • Sinus tachycardia
      • Incomplete right bundle branch block
      • ST elevation consider inferior injury or acute infarct
      • ECG interpretation of ACS is based on presence of symptoms and ST elevation in Inferior leads with Reciprocal ST depression in Anterior leads and T-wave inversion in Septal leads
    • 2022-07-12 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 28.0) / 99.3 = 65.56%
        1. Sub-optimal echo window
        1. Normal AV/MV with no AR/MR
        1. Concentric LVH
        1. Preserved LV and RV systolic function
        1. No PR/TR, dilated IVC
    • 2022-07-08 CT - brain
      • A soft tissue tumor (1.5cm) at left CP angle cistern r/o meningioma.
      • Brain atrophy. Sinusitis.
  • consultation
    • 2022-08-15 Dermatology
      • Q
        • At ONC ward, vital signs stable and we will explained the current condition to patient and family.Radiothist was consulted for radiotherapy and started on 2022/08/12.
        • However, his skin rash was noted during hospitalization. we need your expertise further management, thanks
      • A
        • This patient suffered from mutiple erytheamtous patches on trunk and 4 limbs for days.
        • IMp: Tinea corporis
        • Suggestion: Zalain cream * 2 tubes/bid
    • 2022-08-05 Radiation Oncology
      • Q
        • This is a 81 years old male with uderlying disease of DM, HTN, dementia. He was admission due to suffered from a consciousness change since 20220707. Palpitations, shortness of breath, dyspnea, pyuria, spiky fever and generalized malaise for 2 days were noted. Then the patient was brought to our ER for help. Con’s: E2V2M4, O2 saturation: 87%. The laboratory data showed leukcoytosis and elevated of CRP level, acute kidney injury was also noted BUN 143 / Cr 5.5. The urinlyais showed UTI picture, the CXR film showed bilateral infiltration, under the impression of sepsis, pneumonia and UTI related, then he was admission to INF ward for further management on 2022-07-10. At ward, NG insert for prevent chocking. The antibiotic Avelox plus Tapimycin on 2022/07/11. We discuss with families, they decided DNR except medication. Due to unstable hemodynamic condition, he was transferred to MICU for further treatment on 2022/07/11.
        • < MICU course 20220711-0728 > At MICU, we kept the antibiotics of Tapimycin (20220711-0720) and Ciproxin (20220712-0719). NRM was changed to V-M 12L/min and the patient was tolerant. We added inhalation medication for COPD. Cardiac echo was arranged and showed normal wall motion. Cardiologist was consulted for AF control. Diltiazem and Plavix were suggested. For weak cough function and much sputum, VEST was arranged (20220716-0726). Hypernatramia was improved after adequate IV and oral water. The patient’s respiratory pattern was getting smoother under treatment. However, brick-red stool was noted since 20220717 night. Plavix was hold. Sidmoidoscopy revealed erosion with oozing, susp tumor bleeding. Thus we consulted CRS then abdominal CT was suggested. We also explained to his family about the condition, they favor conservative treatment. The abdominal CT showed Sigmoid adenocarcinoma, cT3N1aM0, stage IIIB. We added Albumin and lasix for generalized edema and kept I/O negative. Less brick-red stool noted thus NG diet was given. Antibiotic was shifted to Curam (20220721~). Under stable condition, he was transferred back to ordinary ward on July 27, 2022.
        • < Ward course 7/28~ > After he was transferred to our ward, we kept Curam for prophylactic treatment. Smooth respiratory under nasal cannula used. We consulted Oncology for colon cancer evaluation and management. Intermittent brick-red stool and black stool passage under Transamin iv treatment. L-PRBC transfusion was done for Anemia. The general condition was improvment and stationary. Today, he will be transferred to the oncology ward and taken over by oncologist chief Chang for further cancer further management on Aug 03, 2022. At ONC ward, vital signs stable and we explianed the current condition to patient and family, they agree the radiotherapy therapy. We need your expertise for radiotherapy evaluation, thanks.
      • A
        • This 81 y/o male sufferred from bloody stool. The abdominal CT showed Sigmoid adenocarcinoma, cT3N1aM0, stage IIIB. Due to poor general condition, surgery or chemotherapy is not feasible, according to his daughter.
        • Palliative RT for bleeding control and obstruction prevention is indicated. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 54 Gy/ 30 fx. However, due to he’s bed-ridden now, his daughter will ask if he can stay at the ward during the whole radiotherapy course. If he can, CT-simulation will be arranged accordingly. Thank you very much.
    • 2022-07-18 Colon and Rectal Surgery
      • Q
        • Episodes of bloody stool passaged and Hgb drop was noted, LPRBC 2U *2 days(20220717-0718) and sigmoidoscopy of 20220718 which showed suepected cancer with bleeding related (about 20cm AAV). We need your expert to evaluate his condition. Thank a lot!
      • A
        • wait sigmoidoscopy report
        • Blood transfusion and resuscitation as needed
        • suggest CT to evlaution if cancer is highly suspected.
    • 2022-07-13 Cardiology
      • Q:
        • We need your expertise for evaluation and suggestion of elevated hsTnI and AF medication. Thanks a lot!
        • hs-Troponin I                      
          • 2022-07-08 21:39 11899.3 pg/mL          
          • 2022-07-09 00:11 13997.4 pg/mL          
          • 2022-07-09 06:57 12819.3 pg/mL          
          • 2022-07-09 20:18 11471.6 pg/mL       - A
        • This is a 81 years old man who was admitted for urosepsis with pneumonia. Has consent for DNR. We were consulted for elevated trop and Af
        • Cardiac echo 20220713 EF: 65%
            1. Sub-optimal echo window
            1. Normal AV/MV with no AR/MR
            1. Concentric LVH
            1. Preserved LV and RV systolic function
            1. No PR/TR, dilated IVC
    • 2022-04-07 Orthopedics
      • Q
        • fell down on the groung
        • lower back pain, bil hip pain, right knee pain
        • could not weight bearing
        • ILOC (-), head injury (-)
        • Allergy: -
        • Past history: dementia, DM, HTN
        • Exposure (TOCC): denied
        • Trauma hx: denied
      • A
        • 81 y/o M
        • A: right knee pain and right ankle pain, suspected patella and ankle fracture
        • P: long leg splint and OPD follow-up

[assessment]

  • Na (2022-09-04 132 mmol/L <- 2022-09-03 126 mmol/L), K (2022-09-04 3.9 mmol/L <- 2022-09-03 6.1 mmol/L). Hyperkalemia and hyponatremia have been alleviated.
  • In spite of the fact that AKI in July has improved, kidney function has decreased over the past week. (Cre 2022-09-03 1.35 mg/dL <- 2022-08-24 1.03 mg/dL, BUN 2022-09-03 33 mg/dL <- 2022-08-24 27 mg/dL)
  • If the patient’s kidney function deteriorates, the dose of tranexamic acid, Fylin (pentoxifylline), Glucophage (metformin), and Feburic (febuxostat) listed in active prescription might need to be adjusted.

701431395

220905

{Lung cancer at right lower lung, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, stage IV, with mukltiple brain metastasis, PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+)}

  • lab data
    • 2022-07-07 HBsAg Nonreactive
    • 2022-07-07 HBsAg (Value) 0.29 S/CO
    • 2022-07-07 Anti-HBs 263.06 mIU/mL
    • 2022-07-07 Anti-HCV Nonreactive
    • 2022-07-07 Anti-HCV Value 0.20 S/CO
  • exam finding
    • 2022-09-02, -08-29 CXR
      • Patchy opacity of the right lower lung zone and several nodular opacity projecting at both lung are noted that may be primary lung cancer with lung to lung metastases. Please correlate with CT.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Patchy consolidation of the right middle lung zone is suspected. Please correlate with clinical condition or CT.
    • 2022-08-26 KUB
      • S/P wires projecting at the midline abdominal and pelvic wall.
      • Fecal material store in the colon.
      • Compression fracture of T12 vertebral body.
    • 2022-08-24 MRI - C-spine
      • heniated discs in the C3/4, C4/5, C5/6 and C6/7 discs, more on the C6/7 disc.
      • spinal canal stenosis at the middle and lower C-spine.
    • 2022-08-22 MRI - L-spine
      • After IV contrast administration shows well or heterogenous enhancement at C4,5 bodies, metastases?
    • 2022-08-22 ECG
      • Normal sinus rhythm
      • Possible Left atrial enlargement
      • Poor wave progression V1~4
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-07-26 PD-L1 IHC
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percentage of 28-8 expressing tumor cells (%TC): 0%
    • 2022-07-26 PD-L1 22C3
      • Tumor Proportion Score (TPS) category: TPS < 1%
    • 2022-07-26 PD-L1 (SP142)
      • Result:
        • Tumor cell (TC) staining assessment: TC category: TC < 1%
        • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-07-26 ROS1 FISH
      • ROS1 fluorescent-in-situ hybridization report - rearrangement of ROS1 gene is NOT detected. Patient with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
    • 2022-07-26 EGFR mutation
      • Two mutations were detected at exon 19 (Del) and exon 20 (T790M) of EGFR gene in this specimen.
    • 2022-07-12 Tc-99m MDP whole body bone scan with SPECT
        1. Mildly increased activity in the lower C-spine, lower T-spine and L5-sacrum junction. Degenerative change is more likely.
        1. Increased activity in the maxilla and mandible. Dental problem may show this picture.
        1. A faint hot spot in the anterior aspect of left 1st rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulders, left wrist, bilateral hips and right knee, compatible with benign joint lesions.
    • 2022-07-11 Patho - lung wedge biopsy
      • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
      • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
    • 2022-07-09 CXR
      • Patchy opacity of the right lower lung zone and several nodular opacity projecting at both lung are noted that may be primary lung cancer with lung to lung metastases. Please correlate with CT.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • 2022-07-09 MRI - brain
      • Multiple bil. brain and upper left brain stem metastases, more prominent at left cerebellum and left frontal lobe.
    • 2022-07-07 ECG
      • Normal sinus rhythm
      • Possible Left atrial enlargement
      • Poor wave progression V1~4
      • Abnormal ECG
  • consultation
    • 2022-08-26 Rehabilitation
      • A
        • Due to 4 limbs weakness, we were consulted for bedside PT rehabilitation programs.
        • MP:
          • RUL/RLL: 4/3 LUL/LLL: 4/3 (before Radiotherapy, MP was 2-3/3; 4/3)
        • Functional status: needs min assistance
        • BADL: needs miin assistance
        • Assessment
          • Lung cancer at right lower lung, adenocarcinoma
          • HTN
          • HIVD, heniated discs in the C3/4, C4/5, C5/6 and C6/7 discs, more on the C6/7 disc.
        • Plan
          • arrange rehab OPD after discharge for further Rehabilitation programs: PT rehabilitation programs
        • Goal: improve endurance and muscle strength
      • 2022-08-30 supplement
        • The discharge plan was posponed due to unstable condition and fever. We were consulted today for arrangement of rehab training.
        • Fever 38.1-38.3’C with chillness was noted when I visited.
        • Consciousness: intact
        • Cognition: intact, oriented, could follow orders
        • Mobility: lying on bed due to discomfort and general weakness.
        • Plan
          • Rehabilitation programs: Bedside PT rehabilitation programs
          • Goal: improve endurance and muscle strength
    • 2022-08-24 Radiation Oncology
      • Q
        • Brain MRI (20220709): Multiple bil. brain and upper left brain stem metastases, more prominent at left cerebellum and left frontal lobe. Consult radiation oncology for CT-guide biopsy at right lung the report showed RLL lung mass, s/p CT-guided biopsy. Minimal pneumothorax on 20220709. The biopsy report showed adenocarcinoma, moderately differentiated, immunohistochemical stains reveal TTF-1(+) and Napsin A(+), PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+). And received radiotherapy with dose: 660cGy/2 fractions (6 MV photon) to brain metastasis, 2022/07/29-2022/08/01, then RT dose: 2310cGy/7 fractions (6 MV photon) to brain metastasis, 2022/08/01-2022/08/08, RT dose: 3960cGy/12 fractions (6 MV photon) to brain metastasis, 2022/08/08- 2022/08/15, the targeted therapy as Afatinib 1tab QOD since 2022/08/09.
        • This time, she came to radiation oncology OPD foloow-up, then complaints bilateral lower limbs weakness and lethargy for two weeks, and suspect intramedullary metastasis and spinal cord compression, so she was transferred to our ER for help. At ER, followed-up chest X-ray showed a mass lesion in right lower lung zone, the L-spine MRI (20220822) showed: no obvious spinal cord mass or nodule. After IV contrast administration shows well or heterogenous enhancement at C4,5 bodies, metastases? we already arrange the C-spine MRI on 20220824. So we need your help, thanks a lot!!
      • A
        • O
          • Past Hx: HTN(-); no DM.
          • Initial presentation with clonus over right side.
          • Lung nodule noted in 2022-04; Brain CT on 2022-06-16: multiple bran metastasis.
          • Rt hemiweakness for 1-2 months.
          • 2022/07/11 PATHO-Lung wedge biopsy: adenocarcinoma, moderately differentiated.
          • immunohistochemical stains reveal TTF-1(+) and Napsin A(+), PD-L1: TC < 1%, IC < 1%, TPS < 1 %; EGFR Exon 19 deletion and T790M (+).
          • 2022/07/12 bone scan: 1. Mildly increased activity in the lower C-spine, lower T-spine and L5-sacrum junction. Degenerative change is more likely. 2. Increased activity in the maxilla and mandible. Dental problem may show this picture. 3. A faint hot spot in the anterior aspect of left 1st rib. The nature is to be determined (post-traumatic change? other nature?).
          • 2022/07/09 MRI: Brain: Multiple bil. brain and upper left brain stem metastases, more prominent at left cerebellum and left frontal lobe.
          • She has suffered from bilateral lower limbs weakness and lethargy for two weeks.
          • C-T-L spine MRI on 20220822: T-L spines: No obvious spinal cord mass or nodule. Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture at T12, old. No evident tumor like bony destructive lesion. Presence of spondylolisthesis at L5/S1 was found.
          • C-Spine: No obvious spinal cord mass or nodule. After IV contrast administration shows well or heterogenous enhancement at C4,5 bodies, metastases?
          • C spine MRI with contrast, 20220824: high SI change on T2WI in the C6-7 cord; degeerative change in the C-spine disc spaces; moderate decreased disc spaces in the C3/4, C4/5, C5/6 and C6/7 discs. Herniated discs in the C3/4, C4/5, C5/6 and C6/7 discs caused mild anterior indentation on the C3-4, C4-5 and C5-6 cord; severe indentation on the C6-7 cord and moderate left C6-7 foraminal stenosis. Unremarkable change in the bone marrow signal intensity. Degenerative change in the C-spine facet joints. IMP: 1. heniated discs in the C3/4, C4/5, C5/6 and C6/7 discs, more on the C6/7 disc. 2. spinal canal stenosis at the middle and lower C-spine.
        • Imp: Lung cancer, RLL, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, with multiple brain metastasis, ECOG =2;
          • s/p brain RT for 3960cGy/12 fx, 2022/7/29 to 8/15;
          • under targeted therapy as Afatinib 1tab QOD since 2022/08/15.
          • Herniated discs in the C3/4, C4/5, C5/6 and C6/7 discs caused mild anterior indentation on the C3-4, C4-5 and C5-6 cord; severe indentation on the C6-7 cord and moderate left C6-7 foraminal stenosis.
        • Plan: Please consult Rehabilitation & NS for further evaluation. I will F/U this patient at my OPD and arrange follow-up brain MRI for her. Thanks very much for your consultation.
    • 2022-07-08 Radiation Oncology
      • Q
        • For lung CT-guide biopsy
        • The 89 y/o woman has hypertension with Sevikar control at Central Clinic & Hospital. She also has rectal cancer in age 60 at Central Clinic & Hospital, stage unknown.
        • She has SOB and fatigue noted in 2022-04, check CXR showed nodule at Central Clinic & Hospital, and then took some bronchodilator and anti-cough medicine control. Suddenly unable to lift right hand during meal time on 20220612 and sent to Central Clinic & Hospital for help.
        • The brain CT showed brain metastasis. She denied BW loss within 3 months. Now, she need family support for walk. She came to our neuro OPD and refered to ONC OPD on 20220630. Under the impression of suspect lung cancer with brain mets, so she was admitted on 20220707.
      • A
        • This 89-year-old patient is a case of right lung mass, suspected malignancy. CT-guided biopsy is indicated.
        • Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • radiotherapy
    • 2022-08-08 ~ 2022-08-15 - 3960cGy/12 fractions (6 MV photon) to brain metastasis
    • 2022-08-01 ~ 2022-08-08 - 2310cGy/7 fractions (6 MV photon) to brain metastasis
    • 2022-07-29 ~ 2022-08-01 - 660cGy/2 fractions (6 MV photon) to brain metastasis
  • chemoimmunotherapy
    • 2022-08-09 ~ Giotrif (afatinib 30mg/tab) 1# QOD

[assessment]

  • 2022-08-30 blood culture result Escherichia coli is currently treated with flomoxef with no issue.
  • 2022-08-30 semifluid stool OB 2+, HGB has been declining (2022-09-05 9.8 g/dL <- 2022-08-22 11.8 g/dL). Possible GI bleeding is treated with pantoprazole 40mg IVD QD currently.
  • BUN/creatinine ratio increases due to a low serum creatinine level (2022-09-05 0.28 mg/dL <- 2022-07-07 0.63 mg/dL) along with a normal BUN level (2022-09-05 17 mg/dL). This elevation in the BUN-to-creatinine ratio is one of the suggestive clinical signs of decreased kidney perfusion (semifluid stool, two to five bowel movements per day in late Aug, volume depletion?).
  • The downtrend in serum creatinine might also be related to muscle loss and/or malnutrition (2022-09-05 albumin 2.8 g/dL).
  • 2D transthoracic echocardiography for heart and flow volume loop and volume time curve for lung were recommended since afatinib is reported relating to cardiovascular and pulmonary toxicity, baseline establishment might be necessary. An ECG recorded on 2022-08-22 indicated possible left atrial enlargement, which might be due to mitral stenosis, mitral regurgitation, or aortic stenosis, which could also be examined with heart doppler sonography.
  • Under Apidra, the blood sugar level remains between 130 and 220 during this hospitalization, there is no urgent need to adjust the dose.

700463704

220902

  • present illness
      1. Hepatitis B carrier,
      1. Hepatocellular carcinoma, pT2NxMx, stage II, BLCL A, Child-pugh A s/p S5 segmentectomy with cholecysectomy on 2013/02/01,
      1. Recurrent HCC s/p S8 segmentectomy, rpT3N0M0,s tage IIIA on 2020/07/08.
      1. Recurrent HCC s/p TACE 7 times on 2015/11/5 ~ 2021/11/26.
  • exam finding
    • 2022-08-22 CXR
      • Mass lesions in both lung zones
      • Right pleural effusion
    • 2022-08-08 CT - chest
      • Findings
        • Lungs:
          • multiple nodules of variable sizes throughout both lungs due to metastases, with relaxation atelectasis of RLL and RML.
          • moderate Rt pleural effusion.
          • further increase in size of a large metastatic tumor at Rt anterior chest wall involving adjacent mediastinum as compared with the previous CT on 20220611.
        • HCC, s/p many surgical resections. further progression of recurrent tumors in both hepatic lobes with tumor thrombi in left portal vein.
        • unremarkable of the spleen, pancreas, both kidneys, and both adrenal glands. no ascites or emlarged lymph nodes.
      • Impression:
        • recurrent HCC with lung and chest wall metastases, further in progression as compared with the previous CT on 2022/06/11.
    • 2022-08-04 Tc-99m MDP whole body bone scan with SPECT
        1. Mildly increased activity in some L-spines. Degenerative change may show this picture.
        1. Some faint hot spots in bilateral rib cages and increased activity in the sternum. The nature is to be determined. Please correlate with other clinical findings and follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulsers, sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2022-06-11 CT - abdomen
      • Findings
          1. HCC, s/p operation. Progression of recurrent tumors in both hepatic lobes.
          1. Tumor thrombi in left portal vein.
          1. Right chest wall mass lesion, in progression.
          1. No ascites, nor extraluminal free air.
          1. No bony destructive lesion on these images.
      • Impression
        • Recurrent HCCs, in progression
        • Left portal vein thrombosis
        • Right chest wall metastasis, in progression
    • 2022-06-11 CXR
      • Focal upward bulging of right diaphragm is noted. please correlate with clinical condition or CT.
    • 2022-04-01 Patho - pleural/pericardial biopsy
      • Labeled as “R superior chest wall tumor”, CT-guided biopsy — poorly differentiated carcinoma.
      • IHC stains: CK (+), GATA-3 (+), mammoglobin (-), E-cadherin (-), hepatocyte (-), Arginase-1 (-), AFP (-), ER (-), PR (-), Her2/neu: negative (score = 0), Ki-67: 90%.
      • Section shows soft tissue with infiltration of trabeculae of poorly differentiated carcinoma.
    • 2022-04-01 CXR
      • Focal upward bulging of right diaphragm is noted. please correlate with clinical condition or CT.
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2022-03-21 CT - chest
      • Findings
        • Lungs: subtle mosaic attenuation in both lower lobes and posterior both Lt upper lobe. old calcified LN in the left anterior prevascular space, sequela of previous TB infection
        • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
        • Heart: normal in size of cardiac chambers.
        • Pleura: no effusion or nodule.
        • Chest wall: Rt thyroid lobe calcification 11 mm.
          • a well-defined soft-tissue mass with cystic and solid components (16x27x16 mm) at Rt paramedian superior anterior chest wall (beneath the pectoralis msucle).
        • Visible abdo > S/P resection of right lobe liver.
          • poor enhancing iInfiltrative tumor in left lobe liver and enhancing tumor (2 cm) in S7 liver due to recurrent HCCs.
          • Presence of central portal venous thrombosis.
        • unremarkable of the spleen, adrenal glands, pancreas, and kidneys.
        • Visualized bones: unremarkable.evaluation.
      • Impression:
        • Rt superior anterior chest wall mass, metastatic tumor or a primary intercostal chest lesion.
    • 2022-02-26 CT - abdomen
      • Findings
        • S/P resection of right lobe liver.
        • Infiltrative tumor in left lobe liver, enhancing tumor (2cm) in S7 liver, could be due to recurrent HCCs.
        • Presence of portal venous thrombosis, progression.
      • Impression:
        • S/P resection of right lobe liver.
        • Recurrent HCCs with progression of portal venous thrombosis.
    • 2022-01-10 MRI - liver, spleen
      • Findings:
          1. There are two ill-defined masses, measuring 2.4 cm in S7 dome and 3.1 x 2.7 cm in S4 of the liver. During dynamic study, two masses show contrast enhancement in arterial phase images and no significant evidence of contrast washout in portal venous phase and delayed phase images.
          • HCCs are highly suspected.
          • In addition, The S4 lesion shows hypointensity on T1WI and it directly connected with left portal vein thrombosis.
          • Recurrent HCC at S4 with directly invasion causing portal vein tumor thrombsis is highly suspected.
          1. Prior CT suspected Two ill-defined poor enhancing area in left lobe liver are not noted in the current MRI that are c/w flow artifacts.
          1. Prior CT identified an ill-defined enhancing lesion measuring 2.9 x 2.6 cm in S2/3 of the liver at arterial phase images is not noted in the current MRI and the mechanism may be hyperemia (compensatory increased arterial flow in arterial phase images secondary to portal vein thrombosis).
          1. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
          • There is mild esophageal varices that may be portal hypertension.
          1. S/P cholecystectomy. S/P partial resection of S5 and S8 of the liver.
      • Impression:
          1. Two recurrent HCCs on S7 dome and S4 are suspected.
          1. Recurrent HCC at S4 causing left lobe portal vein tumor thrombosis is highly suspected.
    • 2022-01-05 CT - abdomen
      • Findings:
          1. There are three ill-defined iso-hypodense lesion, measuring 2.4 cm in S7 dome, 2.9 x 2.6 cm in S2/3, and 3.2 x 2.6 cm in S4, of the liver. During dynamic study, all masses show contrast enhancement in arterial phase images and Eqivocal contrast washout in portal venous phase and delayed phase images.
          • HCCs are highly suspected.
          1. Two ill-defined poor enhancing area in left lobe liver are suspected and non-enhancement of left portal vein.
          • Please correlate with MRI to R/O infiltrative type HCCs with tumor thrombosis in left portal vein.
          1. The liver shows irregular contour and atrophy of segment 4 that is consistent with cirrhosis.
          • There is mild esophageal varices that may be portal hypertension.
          1. S/P cholecystectomy. S/P partial resection of S5 and S8 of the liver.
      • Impression:
          1. Three recurrent HCCs on both hepatic lobes are suspected.
          1. Infiltrative type HCCs at left hepatic lobe with tumor thrombosis in left portal vein are suspected.
        • Please correlate with MRI.
    • 2021-10-04 MRI - liver, spleen
      • Findings
        • HCC s/p operation and TACE. Some small marginal enhancing nodules (up to 1.7cm) in both hepatic lobes.
      • IMP:
        • HCC s/p operation and TACE. Some small marginal enhancing nodules (up to 1.7cm) in both hepatic lobes c/w tumor recurrence.
    • 2021-09-29 SONO - abdomen
      • Hepatic tumor suspected HCC (inconspicuous)
      • Liver cirrhosis
      • post cholecystectomy
    • 2021-08-14 CT - abdomen
      • Findings
        • s/p cholecystectomy and S5 resetion.
        • Hypervascular hepatic tumor at S4 of liver up to 1.94cm in largest dimension. Suggest closely follow up.
        • The portal vein and IVC are patent.
        • Another low density lesion at dome about 2.0cm in largest dimension. HCC?
        • Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis. Suggest clinical correlation
      • Imp:
        • Suspected hepatic tumors at S4 and S5 of liver. Suggest correlate with other findings.
    • 2021-06-11 SONO - abdomen
        1. A hypoechoic lesion 1.49 cm in S2/3 of the liver is noted that may be tumor or fat sparing area. Please correlate with contrast enhanced dynamic CT or MRI.
        1. S/P partial resection of S7-8 of the liver and cholecystectomy.
    • 2021-03-08 MRI - liver, spleen
      • HCC s/p operation and TACE without enhancing tumor.
    • 2021-03-08 SONO - abdomen
      • Liver lesion, nature?
      • Liver cirrhosis, mild fatty liver
      • Post cholecystectomy
      • Fatty pancreas
    • 2021-02-01 MRI - liver, spleen
      • HCC s/p operation and TACE. A recurrent HCC (1.8cm, srs8, img23) at liver dome.
    • 2020-11-28 CT - abdomen
      • Liver cirrhosis with HCC s/p S5 and S8 op. with borderline enhanced region at S7 just near previous TACE region. Suggest closely follow up.
    • 2020-09-08 SONO - abdomen
      • S/P cholecystectomy and partial resection of S7-8 of the liver.
    • 2020-07-09 Patho - liver partial resection
      • pathologic diagnosis
          1. Liver, S8, segmental hepatectomy — Hepatocellular carcinoma, recurrent
          1. Pathologic Staging: rpT3Nx; Stage IIIA at least
      • microscopic examination
          1. Histologic Type: Hepatocellular carcinoma, trabecular type with focal intratumoral fibrosis
          1. Histologic Grade: Poorly differentiated (G3)
          1. Tumor Necrosis: Present
          1. Tumor Capsule: Encapsulated with focal infiltrative border
          1. Tumor Extension: Tumor confined to liver
          1. Large Vessel Invasion: Not identified
          1. Small Vessel Invasion: Present
          1. Perineural Invasion: Not identified
          1. Pathologic Staging (rpTNM): Stage IIIA at least (rpT3Nx)
          1. Margins
          • 10.1 Parenchymal Margin: Free, 1.6 cm from closest margin
          • 10.2 Hepatic Capsule: Uninvolved by invasive carcinoma
          1. Additional Pathologic Findings: Small cell and large cell changes
          1. Hepatitis (specify type): Hepatitis B
          1. Ishak Modified HAI Grading: Score=3 (interphase hepatitis = 1/4, confluent necrosis = 0/6, focal necrosis = 0/4, portal inflammation = 2/4) (Corresponding Metavir A1, mild activity)
          1. Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
          1. Fatty Change: Present (10%)
    • 2020-05-30 CT - abdomen
      • Hepatic tumor at dome, recurrent HCC is considered.
    • 2020-05-23 SONO - abdomen
      • Liver tumor: suspect HCC
      • Liver cirrhosis, mild fatty liver
      • post cholecystectomy
    • 2020-02-14 SONO - abdomen
      • Findings:
          1. Status post partial resection of S5/8 of the liver.
          • The residual liver shows normal in size and echogenicity without focal lesion.
          • Portal vein flow: patent.
          • Bile ducts: not dilated.
          1. Status post cholecystectomy.
          1. The pancreatic head and body shows normal in size and texture.
          • The pancreatic tail is obscured by overlying bowel gas.
          1. The spleen shows normal in size and echogenicity without focal lesion.
          1. Abdominal aorta and IVC show unremarkable finding.
          1. There is no evidence of para-aortic lymphadenopathy or ascites.
          1. Both kidney show normal echopattern and size.
          • There is no evidence of stone or hydronephrosis.
      • Impression:
          1. S/P cholecystectomy and partial resection of S5/8 of the liver.
          1. Otherwise, no significant abnormal finding is noted.
    • 2019-10-05 CT - abdomen
      • HCC s/p operation and TACE without viable tumor.
    • 2019-08-26 SONO - abdomen
      • HCC, Status post partial right segmentectomy (S5/8)
      • Liver tumors?
      • Liver cirrhosis
      • Status post cholecystectomy
    • 2019-06-08 CT - abdomen
      • HCC s/p operation and TACE without viable tumor.
    • 2019-03-04 SONO - abdomen
      • Liver cirrhosis
      • Status post cholecystectomy
      • Status post partial right segmentectomy (S5/8)
    • 2018-12-01 CT - abdomen
      • HCC s/p operation and TACE without viable tumor.
    • 2018-09-07 SONO - abdomen
      • Suspected chronic liver parenchyma disease (Please correlate with liver function)
      • Suspected early cirrhosis
      • C/w partial segmentectomy,right liver
      • S/p cholecystectomy
      • Suboptimal examination of liver due to poor echo window
    • 2018-07-16 SONO - abdomen
      • Liver cirrhosis
      • Liver nodules?
      • Status post cholecystectomy
    • 2018-06-16 CT - abdomen
      • Liver cirrhosis.
      • HCC s/p wedge resecion. No local recurrence
    • 2018-03-17 CT - abdomen
      • HCC s/p operation and TACE with minimal viable tumor.
    • 2018-01-08 SONO - abdomen
      • HCC s/p segmentectomy
      • Liver lesions, nature?
      • Parenchymal liver disease
      • Status postcholecystectomy
    • 2017-12-23 CT - abdomen
      • HCC s/p operation and TACE. A residual HCC (1.5cm) at S8 of liver.
    • 2017-09-30, 2017-07-08, 2017-04-15 SONO - abdomen
      • liver cirrhosis/ incomplete exam of liver
      • GB sac not seen
    • 2017-01-24 SONO - abdomen
      • Liver cirrhosis
      • Post cholecystectomy
  • surgical operation
    • 2020-07-08
      • Surgery
        • S8 resection
        • adhesivelysis
      • Finding
        • S8 recurrent tumor 5.5 x 5.0 x 3.5 cm
        • severe adhesion of liver and T-colon and diaphragm due to previous operation
        • mild liver cirrhosis
    • 2014-03-27 Hemorrhoidectomy
      • Hemorrhoids with a papillar lesion at 7 oclock position, another at 3 oclock position.
    • 2013-02-01 S5 segmentectomy with cholecysectomy
  • Transarterial Chemoembolization, TACE
    • 2022-01-14 Embolization (TAE, TACE) - doxorubicin
    • 2021-11-26 Embolization (TAE, TACE) - doxorubicin
    • 2021-02-18 Embolization (TAE, TACE) - doxorubicin
    • 2020-06-09 Embolization (TAE, TACE) - doxorubicin
    • 2018-04-13 Embolization (TAE, TACE)
    • 2018-01-19 Embolization (TAE, TACE)
    • 2016-09-02 Embolization (TAE, TACE)
    • 2015-11-05 Embolization (TAE, TACE)
  • chemoimmunotherapy
    • 2022-08-15 - cisplatin 40mg/m2 80mg 2hr + fluorouracil 2000mg/m2 4000mg 22hr (2002-08-08 CT progressive disease)
    • 2022-08-01 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-07-18 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-07-04 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-06-20 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-06-06 - oxaliplatin 80mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-05-23 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-03-19 ~ 2022-05-10 - sorafenib 200mg/tab 2 BIDAC
    • 2022-03-11 - nivolumab 100mg 1hr
    • 2022-02-08 - nivolumab 100mg 1hr
    • 2022-01-14 - nivolumab 100mg 1hr
    • 2021-12-03 ~ 2021-12-31 - sorafenib 200mg/tab 1 BIDAC
    • 2021-02-26 ~ 2021-10-26 - sorafenib 200mg/tab 1 BIDAC
    • about one year, when? - lenvatinib

==========

2022-09-02

  • Cisplatin was introduced during the last hospital stay (2022-08-15), but there are no hearing test records (e.g. pure tone audiometry) available. Prior to accumulating too much dose, it is recommended to obtain a baseline measurement.

2022-08-23

  • Apresoline (hydralazine) and Sevikar (amlodipine + olmesartan) reduced blood pressure from 181/108 (2022-08-22 19:46) to 153/87 (2022-08-23 08:44).
  • If cellulitis of lower limbs is still a diagnosis, then parenteral antibiotics without an indication for MRSA in higher risk patients could be:
    • cefazolin 1 to 2 g IV Q8H
    • oxacillin 1 to 2 g IV Q4H

700994233

220901

  • family history
    • mother: cervical cancer
    • father: parkinson’s disease
  • lab data
    • 2022-08-25 Anti-HBc Reactive
    • 2022-08-25 Anti-HBc-Value 5.79 S/CO
    • 2022-08-25 Anti-HBs 58.45 mIU/mL
    • 2022-08-19 HBsAg Nonreactive
    • 2022-08-19 HBsAg (Value) 0.42 S/CO
    • 2022-08-19 Anti-HCV Nonreactive
    • 2022-08-19 Anti-HCV Value 0.09 S/CO
  • exam finding
    • 2022-08-26 Patho - liver biopsy needle/wedge
      • Liver, EUS-FNB — Adenocarcinoma, pancreatobiliary type, moderately differentiated
      • The sections show a picture of adenocarcinoma, pancreatobiliary type, moderately differentiatrf, composed of liver tissue with nests, cords, and single cuboidal to low columnar neoplastic cells with glandular differentiation in fibrous stroma. Intracellular and extracellular mucin secretion can be found.
      • IHC shows: CK7(+), CA19-9(+), CK20(-), and CDX2(-).
    • 2022-08-26 Needle Aspiration Cytology - pancreas
      • Indication: suspected pancreas cancer with liver metastasis, T3N2M1, stage IV
      • Pathologic diagnosis: pancreatic tumor, suspicious for malignancy
    • 2022-08-26 Endoscopic Ultrasonography, EUS
        1. Pancreatic body tumor, s/p CH-EUS & EUS/FNB (B)
        1. Liver tumor, favor metastatic lesion, s/p CH-EUS & EUS/FNB (A)
        1. Suspected SMV thrombus or tumor direct invasion to SMV
    • 2022-08-22 CT - abdomen
      • Findings
        • A poor enhancing tumor (2.7x4.7cm) in pancreatic body and tail with adjacent fat stranding.
        • Multiple liver tumors.
        • Some soft tissues in peritoneal cavity with ascites.
        • Some LNs at retroperitoneum.
      • Imaging Report Form for Pancreatic Carcinoma
        • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
    • 2022-08-19 Esophagogastroduodenoscopy, EGD
      • erosive esophagitis LA Classification grade A
      • superficial gastritis, post CLO test
      • gastric erosions, multiple, whole stomach
    • 2022-08-19 SONO - abdomen
      • Liver tumors, multiple, nature?
      • Parenchymal live disease
      • Borderline splenomegaly
      • Minimal ascites
      • Gall stones

[note]

  • 2022-09-01 Pilian (cyproheptadine 4mg/tab) 1# TID - off-label: Decreased appetite secondary to chronic disease; Serotonin syndrome; Spasticity associated with spinal cord damage
    • Efficacy and Tolerability of Cyproheptadine in Poor Appetite: A Multicenter, Randomized, Double-blind, Placebo-controlled Study - https://sci-hub.se/10.1016/j.clinthera.2021.08.001
    • Cyproheptadine: Drug information - https://www.uptodate.com/contents/cyproheptadine-drug-information (2022-09-01)
      • Dosing: Adult
        • Appetite, decreased secondary to chronic disease
          • Appetite, decreased secondary to chronic disease (off-label use): Oral: Initial: 2 mg 4 times per day for 1 week, then 4 mg 4 times per day (Homnick 2004; Homnick 2005).
        • Serotonin syndrome, moderate
          • Serotonin syndrome (serotonin toxicity), moderate (off-label use):
            • Note: Reserve for patients with agitation despite discontinuation of serotonergic agent(s), adequate sedation (eg, with a benzodiazepine), and supportive care (Boyer 2005; Sun-Edelstein 2008).
            • Oral: Initial: 12 mg once followed by 2 mg every 2 hours until clinical response. Maintenance: 4 to 8 mg every 6 hours as needed. Maximum dose: 32 mg/day (Boyer 2005; Sun-Edelstein 2008).
        • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
      • Dosing: Kidney Impairment: Adult
        • No dosage adjustment provided in manufacturer’s labeling. However, elimination is diminished in renal insufficiency.
      • Dosing: Hepatic Impairment: Adult
        • No dosage adjustment provided in manufacturer’s labeling.

701037871

220830

{hypopharynx squamous cell carcinoma, cT3N1M0}

  • diagnosis
    • 2022-08-16 discharge diagnosis
      • 1: Squamous cell carcinoma, posterior wall of hypopharynx, cT3N1M0, stage III status post port-A catheter implantation, tracheostomy, and laparoscopic gastrostomy and on 2022-07-21
      • 2: Ventral hernia status post repair of ventral hernia on 2022-08-04
      • 3: Bilateral pleural effusion status post left pigtail catheter insertion on 2022-07-26, and right pigtail catheter insertion on 2022-07-27
      • 4: Liver S6 hemangioma
      • 5: Subcutance emphysema
      • 6: Occlusion and stenosis of right middle cerebral artery
      • 7: Atrial fibrillation
      • 8: Type 2 diabetes mellitus without complications
      • 9: Pyuria( urine culture no growth on 2022-07-24)
      • 10: Systemic lupus erythematosus
      • 11: Hypertension
      • 12: Hyperlipidemia
      • 13: Diarrhea, unspecified
      • 14: Insomnia, unspecified
      • 15: Gout, unspecified
  • exam finding
    • 2022-08-26 SONO - chest
        1. left side small amount of pleural effusion
        1. right side moderate amount of pleural effusion over dependent portion, 400cc serosangious fluid was aspirated for analysis.
    • 2022-08-24 CXR
      • left shoulder: Prior arthroplasty
      • Port-A catheter inserted into SVC via left subclavian vein.
      • enlarged cardiac silhoutte; old fracture of multiple Lt ribs
      • Rt greater than Lt bilateral pleural effusions
      • Consolidation and volume reduce over Rt upper lobe
      • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • 2022-08-24 CT - brain
      • Old cerebral infarcts. Mild general brain atrophy. Hypopharyngeal tumor.
    • 2022-08-24 ECG
      • Atrial fibrillation
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-08-12 CXR
      • S/P port-A implantation.
      • S/P endotracheal intubation with the tip beyond the carina
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-08-02 CT - abdomen
        1. S/P gastrostomy.
        1. Bilateral chest wall subcutaneous emphysema.
        1. Liver tumors, r/o hemangiomas.
        1. Dense calcification in right lobe liver.
        1. Bilateral pleural effusion with basal lung atelectasis.
        1. L2-3 compression fractures.
    • 2022-07-29 CXR
      • enlarged cardiac silhoutte; old fracture of multiple Lt ribs
      • Subcutaneous emphysema in the right and left neck and chest wall in regression
      • bilateral pleural effusions s/p pigtail drains placement
    • 2022-07-19 Whole body PET scan
        1. Glucose hypermetabolism in the posterior wall of the hypopharynx, compatible with primary hypopharyngeal malignancy.
        1. Glucose hypermetabolism in some focal areas in the right retropharyngeal and right neck level II areas. Metastatic lymph nodes may show this picture. Please correlate with other clinical findings for further evaluation.
        1. Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
        1. Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
        1. No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2022-07-15 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (107 - 38) / 107 = 64.49%
        1. Preserved LV systolic function with normal wall motion
        1. Dilated LA, LV and RV hypertrophy
        1. c/w RHD with multiple valve involvement (RHD: rheumatic heart disease)
        1. Mild MR, TR and moderate to severe AR
        1. Impaired RV systolic function
    • 2022-07-14 Patho - esophageal biopsy
      • Hypopharynx, posterior wall, biopsy — Compatible with squamous cell carcinoma and ulcer
      • Microscopically, the sections show a picture of high grade dysplasia of squamous epithelium with focal squamous cell carcinoma in situ, ulcer with inflammatory exudate and necrotic debris, and inflamed, scant stroma with focal epithelial budding or few isolated nest, compatible with squamous cell carcinoma, moderately differentiated.
      • Immunohistochemistry of P16 (-), CK(+), P63(+) and P53(+, diffuse) for tumor. Clinical correlation is advised.
    • 2022-07-13 CT - neck
      • Thickening wall with enhancement at hypopharynx more severe at right side, suspected hypopharyngeal malignancy, suggest further study.
    • 2022-07-13 ECG
      • Atrial fibrillation
      • Nonspecific ST and T wave abnormality
    • 2022-07-13 CXR
      • Increase bilateral lung markings.
      • Mild cardiomegaly.
      • Tortuous thoracic aorta with intimal calcification.
      • Thoracic spondylosis.
      • Post-op at left proximal humerus.
      • Old fractures at left ribs.
    • 2022-07-13 Neck soft tissue
      • No radiopaque foreign body noted.
      • No evidence of prevertebral soft tissue swelling.
    • 2022-07-13 Nasopharyngoscopy
      • smooth NPx, OPx, bulging of R arytenoid (unable to see vocal cord, NBI+), mild saliva pooling at HPx
    • 2022-07-13 Esophagogastroduodenoscopy, EGD
      • Findings
        • Ulcerative change of the mucosa at the posterior wall of hypopharynx with easy touched bleeding with edematous change of the surrounding mucosa. Even the fine-caliber endoscopy couldn’t pass the upper esophageal sphincter.
      • Diagnosis
        • Suspect hypopharynx or esophageal malignancy with obstuction of esophagus, s/p biospy
      • Suggestion
        • neck to chect CT scan
        • monitor her respiratory condition, the risk of apsiration is high. consider intubation if the bleeding persisted
    • 2022-06-11 CT - lung
      • Suspected bil. bronchiolitis.
    • 2022-06-11 Abdomen - supine (diaphragm)
      • S/P NG tube indwelling.
      • Compression fracture of L1-3.
    • 2022-06-11 MRA - brain
      • Brain atrophy with multiple old lacunar brain infarcts.
    • 2022-06-11 ECG
      • Atrial fibrillation with rapid ventricular response
      • LVH with ST T changes
    • 2022-06-10 CXR
      • elongated and tortuosity of thoracic aorta and diffuse calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta
      • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad
      • coliosis of the spine
      • Lt shoulder prior hemiarthroplasty
      • old fracture of many Lt ribs
      • Compression fracture of L1-L3 vertebral bodies
    • 2022-05-16 Swallowing video fluoroscopy
      • Abnormal contour of hypopharynx.
      • Easy chocking during swallowing.
    • 2022-05-12 Nasopharyngoscopy
      • smooth NPx, OPx, HPx, R vocal palsy, mild saliva pooling at HPx
    • 2022-05-05 Neurosonology
        1. Mild (to moderate) atheromatous lesions in bilateral CCA bifurcations; mild atheromatous lesions in bilateral middle to distal CCA.s
        1. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
        1. Poor bilateral temporal windows for transcranial insonation.
    • 2020-12-15 Knee Bilat. standing
      • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation. Osteopenia of visible bones. Loose bodies in the right knee joint.
    • 2020-09-17 ECG
      • Atrial flutter with variable A-V block
      • ST & T wave abnormality, consider inferior ischemia
    • 2020-07-30 CXR
      • cardioemgaly; and mediastinal widening
      • s/p post-OP change in the left humeral bone; and fractures in the left middle ribs.
    • 2020-07-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (128 - 50) / 128 = 60.94%
        1. Adequate LV systolic function with normal resting wall motion
        1. RHD with mild MR; dilated LA (RHD: rheumatic heart disease)
        1. Aortic valve calcification with mild to moderate AS; moderate AR
        1. mild MR, trivial TR
        1. Preserved RV systolic function
        1. Atrial fibrillation at the exam
    • 2020-05-26 Neurosonology
        1. Moderate (to severe) atheromatous lesions in R CCAbifurcation; mild (to moderate) atheromatous lesions in R proximal CCA, L distal CCA to CCA bifurcation; mild atheromatous lesions in L middle CCA, R middle to distal CCA, R ICA, R ECA and R subclavian artery.
        1. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
        1. Poor bilateral temporal windows for transcranial insonation.
        1. Normal bilateral ophthalmic arterial flows
    • 2018-06-19 CT - brain
      • Lacunar infarcts, brain atrophy, and intracranial arteriosclerosis
    • 2018-06-06 Color Transcranial Doppler Sonographic diagnosis:
        1. Mild (to moderate) atheromatous lesions in bilateral CCA bifurcations; mild atheromatous lesions in bilateral distal CCAs and right subclavian artery. Irregular heart beats.
        1. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
        1. Poor bilateral temporal windows for transcranial insonation.
    • 2018-06-06 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 35.6) / 103 = 65-44%
        • Dilated LA
        • Septal hypertrophy
        • Adequate LV and RV performance
        • AV sclerosis with moderate AR ; mild AS
        • Calcified mitral annulus and mitral valve with mild to moderate MR; mild TR and PR
        • Possibly mild pulmonary HTN
        • No regional wall motion abnormalities
        • Atrial fibrillation
    • 2018-06-05 MRA - brain
      • recent lacunar infarct, Rt thalamus.
      • Multiple old lacunar infarcts, deep cerebral hemisphere and pons. Intracranial ICAs and VAs atherosclerosis.
      • Brain atrophy.
      • Bilateral subcortical and periventricular white matter change (leukoaraiosis).
    • 2018-06-05 CT - brain
      • A recent infarct in right centrum semiovale
      • Lacunar infarcts, brain atrophy, and intracranial arteriosclerosis
    • 2018-06-05 ECG
      • Atrial fibrillation
  • consultation
    • 2022-08-02 Oral and Maxillofacial Surgery
      • Q
        • The 76 year-old female with the underlying of
            1. HTN
            1. SLE
            1. type II diabetes mellitus
            1. Atrial flutter
            1. Old CVA of right side
            1. Dysphagia had problem of swollow.
        • The patient had had difficulty in swallowing for 2 months. She visited OPD today for changing of nasogastric tube. She can not restore the new NG tube after the old one removed. The she brought to our ER and ENT with the trying of re-on NG tube but in vain. The CT revealed thickening wall with enhancement at hypopharynx more severe at right side, suspected hypopharyngeal malignancy. So she was admitted to our ward for further management and survey. Panendoscopy show suspect hypopharynx or esophageal malignancy with obstuction of esophagus, s/p biospy. Pathology show Hypopharynx squamous cell carcinoma, cT3N1M0. Then tracheostomy, prot-A and gastrostomy were performed on 2022/07/21. Post operation, she was admitted to SICU for intensive care. After treatment, we started try collar mask trainning, and tried over night well since 2022-07-29. Under stable hemodynamic status, she was transferred to ward for care on 2022-08-01.
        • Further CCRT will be arranged, so we need consult you for pre-RT dental evaluation and management. Thank you very much.
      • A
        • we are consulted for dental evaluation prior to definitive CCRT for hypopharyngeal cancer.
        • As she depends on oxygen treatment via tracheostomy. Bedside physical examination was done.
        • No periodontal disease of full mouth or deep carious teeth were noticed.
        • Plan:
            1. Explain the findings to the patient and her daughter
            1. Oral hygiene reinforcement
    • 2022-08-02 Relabilitation
      • Q
        • Since esophageal malignancy was also suspected accoring to the report of upper gastrointestinal endoscopy, CS was consulted for evaluation of gastrostomy or jejunostomy. With the impression of hypopharyngeal tumor, the patient was admitted for further evaluation and management.
      • A
        • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
        • Premorbid status
          • wheelchair bound
          • heavy hygeiene: maximal assistance
        • Physical examination
          • 2022/08/01 20:11 T/P/R: 36.9℃ / 87bpm / 19bpm BP:114/54mmHg
          • Body weight: 58
          • Consciousness: E4VTM6
          • Cognition: mostly intact; could follow orders
          • Speech: could not speak due to tracheostomy
          • Swallowing: Gastrostomy (+)
          • Sphincter: Foley (+), stool incontinence
          • MP:
            • RUL3 LUL3
            • RLL2 LLL2
          • Functional status: needs max assistance
          • BADL: needs max assistance
        • Assessment
            1. Squamous cell carcinoma, s/p tracheostomy, prot-A and gastrostomy on 2022/07/21
            1. HTN
            1. SLE
            1. type II diabetes mellitus
            1. Atrial flutter
            1. Old CVA of right side
        • Plan
          • Rehabilitation programs: Bedside PT rehabilitation programs
          • Goal: recondition, improve endurance and muscle strength
    • 2022-07-20 Radiation Oncology
      • Q
        • We would like to consult your expertise on arrangement of CCRT for the patient, thank you!
      • A
        • S: For CCRT due to hypopharyngeal carcinoma.
          • PI: The patient with the underlying of 1. HTN 2. SLE 3. type II diabetes mellitus 4. Atrial flutter 5. Old CVA of right side 6. Dysphagia. She can not restore the new NG tube after the old one removed. The she brought to our ER and ENT with the trying of re-on NG tube but in vain. The CT scan revealed thickening wall with enhancement at hypopharynx more severe at right side, r/o hypopharyngeal malignancy. Referred for CCRT.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (quit); Smoking (-); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Allergy(-)
          • Travel Hx(-)
          • Other disease: SLE
          • Previous RT Hx: (-)
        • O:
          • ECOG: 1
          • PE: neck and bil SCF: neg.
          • CXR (2022-7-13): Increase bilateral lung markings. Mild cardiomegaly. Tortuous thoracic aorta with intimal calcification. Thoracic spondylosis. Post-op at left proximal humerus. Old fractures at left ribs.
          • UGI endoscopy (2022-7-13): Suspect hypopharynx or esophageal malignancy with obstuction of esophagus, s/p biopsy.
          • CT scan of neck (2022-7-13): Thickening wall with enhancement at hypopharynx more severe at right side, r/o hypopharyngeal malignancy, suggest further study.
          • Pathology (S2022-11210, 2022-7-18): Hypopharynx, posterior wall, biopsy — Compatible with squamous cell carcinoma and ulcer. Immunohistochemistry of P16 (-), CK(+), P63(+) and P53(+, diffuse) for tumor.
          • PET (2022-7-19): 1.Glucose hypermetabolism in the posterior wall of the hypopharynx, compatible with primary hypopharyngeal malignancy. 2.Glucose hypermetabolism in some focal areas in the right retropharyngeal and right neck level II areas. Metastatic lymph nodes may show this picture.
        • A: Squamous cell carcinoma of the hypopharynx, p16(-), stage cT4aN2bM0 (IVA).
        • P: Radiotherapy is indicated for this patient with the following indicators: advanced stage hypopharyngeal carcinom
          • Goal: curative
          • Treatment target and volume: hypopharyngeal tumor to bilateral neck
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor bed to right neck involved nodal lesions.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started 1330, 2022-7-27.
          • Please consult Dental department for pre-RT dental evaluation and management.
    • 2022-07-15 Cardiology
      • Q
        • After admitted, she was diffcultly swallowing, nutrition supplement under PPN, we will arrange operation with gastrostomy on next W1. The patient recevid Digoxin and Eliquis for Atrial flutter and Old CVA. We need your help for anti-coagulation therapy. Thank you very much!!
      • A
        • S
          • This is a 76 years old lady who was admitted for hypopharynx more severe at right side, suspected hypopharyngeal malignancy. We were consulted for anticoagulant medication.
        • O
          • BP 140/63 HR 84
          • Heart: IRRHB with systolic murmur, Gr II
          • EKG: Permenant Af
          • CxR borderline cardiomegaly
        • As patient is undergoing to receive head and neck operation, a major operation with high bleeding risk procedure (2 days risk of major bleed 2-4%)
        • current problems
            1. Atrial fibrillation
            1. History of mitral valve stenosis and aortic stenosis
            1. diffcultly swallowing; suspected hypopharyngeal malignancy
            1. Suspected CAD (because of coronary artery calcification by chest CT)
        • Suggestion
            1. becauase of patient could not swallowing, she stop Eliquis. maybe shift to enoxaparin 50mg SC Q12H for prevent AF related stroke and for possible CAD.
            1. If patient operation, please stop enoxaparin for one dose (stop enoxaparin 12 hours)
            1. Arrange 2D echo because of hx of AS. MS, and possible CAD
            1. check BW QD and consider check I/O if pulmonary edema
            1. difficulty in swallowing might lead to dehydration, now on TPN, it still risk of fluid overload, maybe check CxR prn if dyspnea or Q3~4Days
            1. if AF HR>110, amiodarone IV is indication.
    • 2022-07-14 Thoracic Surgery
      • A
        • Hpopharyngeal tumor was seen and biopsy was done.
        • Since sophageal malignancy could not be ruled out, I will arrange admission for further evaluation and management.
    • 2022-07-13 ENT
      • A
        • Dysphagia, unable to swallow.
        • Scope: smooth NPx, OPx, bulging of R arytenoid (unable to see vocal cord, NBI+), mild saliva pooling at HPx
        • Imp: Hypopharynx tumor, suspect malignancy
        • Plan:
            1. Pending esophageal biopsy
            1. Gastrostomy for nutrition, patient’s family member agreed
            1. ENT OPD f/u for esophageal biopsy report, futher tx if proved malignancy
  • surgical operation
    • 2022-08-04 Repair of ventral hernia
    • 2022-07-21 Port-A catheter implantation, tracheostomy, and laparoscopic gastrostomy
      • Finding
          1. A 7.0-French Polysite port inserted through left cephalic vein toward superior vena cava for about 20cm long.
          1. The port implanted at upper chest below lateral 1/3 of left clavicle.
          1. Tracheostomy tube: 7.0mm ID Rota-Trach Tracheostomy Tube.
          1. Gastrostomy tube: Cook PEG-24-PULL-S.
          1. Percutaneous endoscopic gastrostomy converted to laparoscopic gastrostomy due to incapability of the upper gastrointestinal endoscope to pass the esophagus.
          1. One liver tumor noted over S6, suspected hemangioma (in GS doctor’s opinion).
          1. Estimated blood loss: 10ml.
    • 2018-06-13 L3 compression fracture
      • Compression of with collapse of the body height 60%
  • radiotherapy
    • 2022-08-12 ~ - at 1000cGy/5 fractions of the hypopharyngeal tumor to bilateral neck.
  • chemoimmunotherapy
    • 2022-08-24 - cisplatin 30mg/m2 45mg 2hr (CCRT)
    • 2022-08-17 - cisplatin 30mg/m2 45mg 2hr (CCRT)
    • 2022-08-12 - cisplatin 30mg/m2 45mg 2hr (CCRT)

[assessment]

  • For the patient’s underlying heart condition, Eliquis (apixaban 5mg) 1# BID had been prescribed by our OPD for routine refilling prior to this hospital stay. The drug is recommended and can also be administered with nasogastric tube.

700945739

220826

  • exam finding
    • 2022-08-26 Whole body PET scan
        1. A glucose hypermetabolic lesion in the pancreatic head. Primary malignancy in the pancreatic head may show this picture. Please correlate with other clinical findings for further evaluation.
        1. Mild glucose hypermetabolism in some abdominal paraaortic lymph nodes. Either inflammatory process or metastatic lymph nodes of low FDG uptake may show this picture.
        1. A mild glucose hypermetabolic lesion in the upper lobe of left lung. The nature is to be determined (inflammation? primary lung malignancy or lung metastasis of low FDG uptake? other nature?). Please also correlate with other clinical findings for further evaluation.
        1. Mild glucose hypermetabolism in the midline anterior abdominal wall, compatible with post-operative inflammation.
        1. Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • 2022-08-05 Patho - gallbladder (benign lesion)
      • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis and cholelithiasis
    • 2022-08-04 CXR
      • S/P right pig-tail catheter indwelling.
      • S/P operation.
      • S/P NG tube indwelling.
      • Right catheterization to SVC in position.
      • S/P Port-A infusion catheter insertion.
      • Ground glass opacity in bilateral lower lungs.
    • 2022-07-28 Flow Volume Loops
      • Mild restrictive ventilatory impairment
    • 2022-07-28 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 33) / 81 = 59.26%
        1. Adequate LV systolic function with normal resting wall motion
        1. Trivial MR and trivial TR
        1. LV diastolic dysfunction, Gr 1
        1. Preserved RV systolic function
    • 2022-07-26 MRI - pancreas
      • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
    • 2022-07-23 CT - abdomen
      • Findings
        • A poor enhancing tumor (3.0cm) at pancreatic head with biliary obstruction and p-duct dilatation. Some small LNs at retroperitoneum.
        • Grade 4 fatty liver.
        • Right renal angiomyolipoma (1.2cm).
        • Distention of gallbladder with stones (2-4mm).
      • IMP:
        • Suspected pancreatic head cancer with biliary obstruction and p-duct dilatation. Grade 4 fatty liver. Right renal angiomyolipoma (1.2cm). Gallbladder stones (2-4mm).
    • 2022-07-23 SONO - abdomen
      • Fatty liver, moderate
      • GB stone, mutliple
      • Dilated CBD
    • 2022-04-11 Patho - stomach biopsy
      • Gastric polyp, body, biopsy — Compatible with fundic gland polyp
    • 2022-04-08 Esophagogastroduodenoscopy, EGD
      • Reflux esophagitis LA grade ASuperficial gastritis
      • Gastric polyps, body and fundus, s/p biopsy
    • 2022-04-08 SONO - abdomen
        1. Fatty liver, severe
        1. GB stone
        1. Renal tumor, suspicious angiomyolipoma of the right kidney
        1. Renal calcinosis, left
        1. pancreatic body masked by gas

700876297

220825

{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}

[objective]

  • Lab findings
    • 2022-05-27 Patho - breast mastectomy with regional lymph nodes
      • pathologic diagnosis
        • Tumor, R’t breast, MRM —- Invasive carcinoma of no special type with focal ductal carcinoma in situ, high grade
        • Resection margins, ditto — Free, closest margin 0.1 cm from base
        • Skin, R’t breast, MRM — Skin ulcer with tumor
        • Nipple, R’t breast, MRM — Free from tumor
        • Lymph nodes, R’t level I/II, dissection — Tumor metastasis (2/18) without extracapsular extension (0/2)
        • AJCC Pathologic Anatomic Stage — ypT4bN1a, cM1, Stage IV and Prognostic Stage — Stage IV
      • microscopic examination
        • Histologic type: Invasive carcinoma of no special type with focal ductal carcinoma in situ, high grade with focal tumor necrosis
        • Size of invasive carcinoma: multiple foci measured up to 5.1 x 2.5 cm
        • Histologic grade (Nottingham histologic score): Grade III (score 9) including [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 3]
        • Margins: Free, closest margin 0.1 cm from base
        • Nodal status: tumor metastasis (2/18)
        • Treatment Effect: post C/T (y)
        • Lymphovascular space invasion: present
        • Perienural invasion: present
    • 2022-05-11 MRI - c-spine
      • Findings
        • Lower vertebral body height, end-plate degeneration, disc collapse with general bulging, posterolateral osteophytes and enlarged facets causing mild canal stenosis and left moderate neuroforaminal narrowing at C5-6-7.
        • No intramedullary abnormality.
      • IMP:
        • Cervical spondylosis, esp C5-6-7 with left neuroforaminal narrowing.
    • 2022-05-05 CT - lung/mediastinum/pleura
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Abnormal skin thickening and nodular lesion up to 1.1cm at right breast is found. In comparison with CT dated on 2022-01-07, marked regression is found.
          • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
          • Small lymph nodes are found at right axillary region. In regression.
          • Fibrotic change at left upper lobe is found. In regression.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Very low density lesion with marginal enhancement at S4 of liver is found. Liver meta is considered. In regression.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
      • Imp:
        • Right breast cancer with right axillary lymph nodes, lung meta and liver meta. All of the tumor activity regression.
    • 2022-05-05 SONO - breast
      • Diagnosis
        • Bil. fibroadenomas
        • Right breast cancer
    • 2022-05-05 Mammography
      • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
        • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
        • Ill-defined mass density at right upper breast, associated with nipple retraction and skin thickening, compatible with breast cancer.
        • No definite enlarged axillary lymph node.
      • Final assessment:
        • BI-RADS category 6, Known Biopsy-proven malignancy. Surgical excision should be considered when clinically appropriate.
        • Right breast cancer.
        • BI-RADS: 6. known biopsy-proven malignancy
    • 2022-01-17 CT - lung/mediastinum/pleura
      • Rt breast cancer with Rt axillary LNs, lungs, and liver metastases, in regression compared with CT on 20211104.
    • 2021-11-04 CT - lung/mediastinum/pleura -Right huge breast cancer with lung meta. Sacrum invasion and liver mets. Stationary.
    • 2021-10-15 CT - abdomen - liver, spleen, biliary duct, pancreas
      • Right breast cancer with right axillary lymph nodes and lung metastases.
      • One metastasis or primary lung cancer in LUL of the lung is suspected.
      • One liver metastasis is highly suspected.
    • 2021-10-15 Tc-99m MDP whole body bone scan with SPECT
      • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture.
      • Increased activity in the maxilla. Dental problem may show this picture.
      • Some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?).
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows, wrists, hips and knees, compatible with benign joint lesions.
    • 2021-10-11 Patho - breast, right, core biopsy; lymph node, right axillary, core biopsy
      • Invasive carcinoma, no special type, NST.
      • IHC stains (using lymph node tissue block S2021-14022):
        • ER (+, 90%, strong intensity),
        • PR (+, 90%, strong intensity, breast mass; +, 50%, strong intensity, lymphonode biopsy),
        • Her2/neu: positive(score=3+),
        • Ki-67 (90%),
        • E-cadherin (+).
    • 2021-10-11 SONO - breast
      • Right breast tumor with enlarged axillary lymph nodes, suspected right breast malignancy, suggest follow up.
      • BI-RADS: Category 5: highly suggestive of malignancy - appropriate action should be taken.
  • chemoimmunotherapy
    • 2022-08-24 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-08-03 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-07-13 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-06-20 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-04-18 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-03-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-03-02 - trastuzumab 600mg SC 5min + pertuzumab 840mg 1hr + docetaxel 75mg/m2 120mg 1hr
    • 2022-02-07 - docetaxel 60mg/m2 98mg 1hr
    • 2022-01-07 - doxorubicin 60mg/m2 95mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)
    • 2021-12-17 - doxorubicin 60mg/m2 95mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)
    • 2021-11-26 - doxorubicin 60mg/m2 95mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)
    • 2021-11-26 - doxorubicin 50mg/m2 80mg 10min + cyclophosphamide 600mg/m2 950mg 1hr (AC)

==========

2022-06-21

  • The ongoing THP (docetaxel + trastuzumab + pertuzumab) since early March 2022 appears to be effective according to a CT scan on 2022-05-05 that all of the tumor activity regression.
  • On the basis of the lab results reported on 2022-06-20, the patient is expected to be able to tolerate the current regimen as in the past.
  • The patient’s TPR, BP, and SpO2 remain stable since being hospitalized, except for intermittent episodes of tachycardia.

2022-03-23

  • As compared to the CT images taken on 2021-11-04, the CT images taken on 2022-01-17 have revealed a partial response to the disease under AC (doxorubicin + cyclophosphamide) regimen administrated during early November 2021 to early January 2022
  • Currently, the patient receives THP (docetaxel + trastuzumab + pertuzumab) since early March 2022.
  • Before the administration of the THP regimen, studies of the heart (echocardiography, 2021-11-05) and lung (CT, 2022-01-17) have been performed to obtain baseline information. Estimated LVEF 61% (based on the echocardiography) and no obvious abnormal laboratory readings were reported on 2022-03-23.

2022-02-08

  • endocrine therapy e.g. tamoxifen might be preferred to aromatase inhibitors
  • trastuzumab, pertuzumab might also be considered if no contraindications

700374742

220823

  • diagnosis
    • 2022-07-26 discharge diagnosis
      • 1: Malignant neoplasm of middle third of esophagus
      • 2: tonsillar fossa tumor with lateral pterygoid muscle with lateral nasopharynx invasion, any node(s) and clinically overt ENE, T4bN3bM0, STAGE:IVB
        • TPF for head and neck cancer
  • lab data
    • Magnesium
      • 2022-07-21 Mg (Magnesium) 1.2 mg/dL
      • 2022-06-30 Mg (Magnesium) 2.7 mg/dL
      • 2022-06-27 Mg (Magnesium) 1.2 mg/dL
      • 2022-06-06 Mg (Magnesium) 2.0 mg/dL
      • 2022-06-02 Mg (Magnesium) 1.4 mg/dL
      • 2022-05-18 1.5 mg/dL
      • 2022-04-29 2.2 mg/dL
      • 2022-04-28 1.2 mg/dL
      • 2022-04-13 1.4 mg/dL
      • 2022-03-17 1.5 mg/dL
      • 2022-03-14 1.5 mg/dL
      • 2021-11-05 1.6 mg/dL
      • 2021-11-03 1.3 mg/dL
      • 2021-10-25 1.4 mg/dL
      • 2021-10-18 1.6 mg/dL
      • 2021-10-04 1.6 mg/dL
      • 2021-09-27 1.5 mg/dL
      • 2020-06-08 1.7 mg/dL
      • 2020-06-03 1.8 mg/dL
      • 2020-05-30 1.8 mg/dL
      • 2020-05-29 2.1 mg/dL
      • 2020-05-28 1.5 mg/dL
    • CEA
      • 2022-04-28 10.607 ng/ml
      • 2022-02-23 4.299 ng/ml
      • 2021-12-01 3.934 ng/ml
      • 2020-08-11 2.202 ng/ml
  • exam finding
    • 2022-07-22 MRI - nasopharynx
        1. Right tonsillar cancer size enlarged, which invades right soft palate and extends laterally to encase right proximal ICA (internal carotid artery) and ECA (external carotid artery).
        1. Right neck lymphadenopathy with ENE (extranodal extension), enlarged.
        1. Post-irradiation change with/without tumor involvement, right lateral nasopharynx, right lateral pterygoid and temporalis muscles.
        1. Progressively swelling of right AE fold (aryepiglottic fold, 杓狀會厭皺襞).
    • 2022-07-21 CXR
      • Scoliosis of the T-spine with convex to right side.
      • Atherosclerotic change of aortic arch
      • A nodular opacity projecting in the right upper lung is suspected. Please correlate with CT.
      • Emphysematous change of both lung field
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-03-16 MRI - nasopharynx
      • The current study was compared to the prior one obtained on 20210924.
      • Knwon a case of right tonsillar cancer S/P treatment. Still mild mucosal thickening of right palatine fossa. Also swollen change of right A-E fold with enhancement. Suggest clinical correlation to rule out inflammatory change or recurrence.
      • Right mastoiditis.
      • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
      • Clear appearacne of all paranasal sinuses.
    • 2022-03-15 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20200605, the lesions in the lower T-spines and some L-spines are stationary. Degenerative change may show this picture.
      • Some new faint hot spots in the posterior aspect of right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
      • No prominent change is noted in the previous faint hot spots in the skull and the lesion in the right femoral shaft, possibly more benign in nature.
      • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips and right knee, compatible with benign joint lesions.
    • 2022-03-09 Nasopharyngoscopy
      • rt arytenoid swelling, limited airway, suggest tracheostomy
      • rt tonsil and mouth floor, p16(-), ct2N2bM0, stage IVa + esophagus ca
    • 2022-02-22 SONO - abdomen
      • A polyp 4.5 mm and multiple stones (< 6 mm) of the gallbladder are noted.
    • 2022-01-12 SONO - head and neck, soft tissue
      • right neck mass, suspected malignancy
      • right neck level II, large, heterogenous mass lesion (tender+), s/p FNA
    • 2021-11-30 MRI - larynx
      • Regressed right tonsil CA, stationary of right carotid and posterior cervical LAPs with central necrotic change.
    • 2021-09-30 CT - lung/mediastinum/pleura
      • Consolidation over posterior segment of right upper lobe.
      • No evidence of metastatic lesion in the current study.
    • 2021-09-28 Patho - gingival/oral mucosa biopsy
      • Observed
        • Hx of R tonsil + mouth floor, esophageal ca s/p incomplete CCRT
        • Mouth floor lesion
      • Diagnosis
        • Labeled as ‘mouth floor lesion’, biopsy — squamous cell carcinoma.
        • Section shows squamous cell carcinoma.
    • 2021-09-28 L-N aspiration
      • R level V LAP, 3*3cm, firm, hard - squamous cell carcinoma
    • 2020-10-23 Patho - esophageal biopsy
      • Esophagus, 30 cm below incisor, biopsy - squamous cell hyperplasia
    • 2020-10-05 CT - lung/mediastinum/pleura
      • RUL infection D/D includes TB or bacteria severe emphysema and fibrotic change in lower lobes.
    • 2020-07-28 Patho - esophageal biopsy
      • A. Labeled as “the lesion needed to ablate is localized at the 19 cm to 35 cm. Random Bx is done (A) as marking at the 19 cm.”, biopsy — squamous mucosa with low grade dysplasia and necrosis.
      • B. Labeled as ‘There is some ablated esophageal tumor tissue retrieved for patho exam (B)’, biopsy - benign squamous mucosa with moderate acute inflammation.
    • 2020-06-30 Patho - tonsil biopsy
      • A. Right side tonsil, frozen section + tonsillectomy — Squamous cell carcinoma, moderately differentiated
        • IHC: CK5/6(+); P16(-), HPV(-) and P63(+) for tumor cells.
      • B. Mouth floor tumor, above wharton’s duct, FS + excision — Squamous cell carcinoma, moderately differentiated characterized by epithelial hyperplasia with high grade dysplasia and focal stromal invasion.
    • 2020-06-30 Frosen section
      • A. Right side tonsil, frozen section — Squamous cell carcinoma
      • B. Mouth floor, ditto — Mild to focal moderate dysplasia
    • 2020-06-29 CT - neck
      • imaging reort form for oropharynx carcinoma
      • Imaging stage: T2N2bM0, stage IVA
    • 2020-06-24 Nasopharyngoscopy
      • Rt NP cyst, Rt tonsils with induration, mouth floor tumor?, hypopharynx cyst.
    • 2020-06-09 Whole body PET scan
      • Mild glucose hypermetabolism involving the middle portion of the esophagus, compatible with primary esophageal malignancy of low FDG uptake. However, no prominent abnormal focal FDG uptake was noted in the lower portion of the esophagus.
      • Mild glucose hypermetabolism in the right tonsil and stomach. The nature is to be determined (inflammatory process? other nature?).
      • Mildly increased FDG uptake in the right anterior neck muscle. Either physiological FDG uptake or mild inflammation may show this picture.
    • 2020-06-08 Miniprobe Endoscopic Ultrasound
      • Esophageal cancer, middle esophagus, EUS estimated stage T1b~T2N1Mx
      • Suspected early esophageal cancer, lower esophagus, EUS estimated stage T1bN1Mx
    • 2020-06-06 CT - lung/mediastinum/pleura
      • u/3 thoracic esophageal cancer T? no evidence of mediastinal invasion, no LAP (N0) and M0.
      • diffuse emphysema, could be related to smoking and fibrotic change in LLL, RLL, and LUL, sequela of prior infection?
      • moderate 3V-CAD.
    • 2020-06-01 Patho - esophageal biopsy
      • pathologic diagnosis
        • A. Lower esophagus, biopsy — High grade dysplasia at least, suspicious for malignancy
        • B. Middle esophagus, biopsy — Squamous cell carcinoma, moderately differentiated
      • microscopic examination
        • A. Lower esophagus: thick epithelium shows high grade dysplasia and few subepithelial connective tissue without tumor invasion. It is still suspicious for malignancy. Repeat biopsy is advised for further evaluation.
        • B. Middle esophagus: squamous cell carcinoma, moderately differentiated characterized by thick epithelium with high grade dysplasia and a few tumor nests infiltrated in inflamed stroma.
          • IHC: CK5/6(+); P16(-), HPV(-), CD34(equivocal) and P63 (+) for tumor cells.
  • consultation
    • 2021-09-30 Radiation Oncology
      • This 53-year-old man previously:
        • MDSCC of Rt tonsil and mouth floor, p16(-), cT2N2bM0, stage IVa, s/p CCRT
        • MDSCC of esophagus M/3, p16(-). cT1b~T2N1M0
      • 2020-06-06 ~ 2020-09-09 RT to the bil. neck, Rt tonsil, LAPs: 50y/ 25fx. The whole esophagus and adjacent lymphatic drainage area: 45y/ 25fx. Postponed since 2020-09-10 because he wanted to take a rest.
      • This time, he suffered from tonsillar fossa tumor with Lateral pterygoid muscle with lateral nasopharynx invasion, Any node(s) and clinically overt ENE, T4bN3bM0, stage IVB. FNA were performed on 2021-09-27. The Labeled as ‘mouth floor lesion’, biopsy (2021-09-29) proved squamous cell carcinoma.
      • Palliative CCRT is indicated. Plan to deliver at least 50 Gy/ 25 fx to the Rt tonsillar tumor, LAPs, and Rt neck level I~III. However, after explanation, he is still afraid of the side effects, such as mucositis or xerostomia, and still need more time to consider whether to have radiotherapy. If he makes up his mind to have radiotherapy, please inform us so we can make arrangement for him. Thank you very much.
    • 2021-09-28 ENT
      • PHx: R tonsil and mouth floor, p16(-), cT2N2bM0, stage IVa; Esophagus cancer, M/3, p16(-), cT1b-T2N1M0 with incomplete CCRT tx
      • Oral: mouth floor whitish lesion s/p biopsy
      • Neck: right level V induration s/p FNA
      • Imp:
        • Right neck mass, suspect malignancy
        • Mouth floor lesion, suspect malignancy
      • Plan:
        • Pending pathology report
        • If unsatisfactory, may consider arrange right neck LAP biopsy under LA
    • 2021-09-22 ENT
      • Local finding: a 3-4 cm indurated non-movable mass with tenderness over R neck level V. A wart-like lesion over midline of floor of mouth.
      • Scope: smooth nasopharynx, oropharynx and hypopharynx. Medialization of right lateral pharyngeal wall. Patent airway.
      • Neck CT a rim-enhanced irregular mass over R level V, increase in size compared to previous study in 2020-06.
      • Neck sono: a heterogenous mass over R neck level V.
      • Impression: Suspect nodal metastasis with or withour necrosis; Mouth floor lesion. Poor nutrition and dehydration.
      • Plan: Admission to Oncology IPD for supportive treatment and further cancer work-up was suggested.
      • NG placement is suggested.
    • 2020-10-27 Radiation Oncology
      • This 52 y/o male patient was diagnosed with
        • MDSCC of Rt tonsil and mouth floor, p16(-), cT2N2bM0, stage IVa
        • MDSCC of esophagus M/3, p16(-). cT1b~T2N1M0
      • s/p incomplete CCRT [20200806 ~ RT to the bil. neck, Rt tonsil, LAPs: 50y/ 25fx. The whole esophagus and adjacent lymphatic drainage area: 45y/ 25fx. Postponed since 20200910 because he wanted to take a rest.]
      • He was admitted due to poor nutrition and pneumonia.
      • To resume CCRT is indicated for double cancer treatment. However, after discussion, he refused to resume CCRT right now and said he will come back for further treatment when he feels better.
    • 2020-05-30 Nephrology
      • This 51 y/o man of chronic alcoholism presented with hypokalemia, hypomagnesemia, and hypocalcemia.
      • PE revealsed severe malnutrition with muscle wasting. The ABG was not remarkable.
      • Hypo-K, hypo-Mg and hypo-Ca are commonly seen in patients with alcoholism and malnutrition, probably due to chronic low intake.
      • This triple electrolyte deficiency is not related to renal tubular dysfunction. Only IV or oral supplements with these electrolytes are needed.
      • I will follow up this patient.
  • surgical operation
    • 2020-07-27 Endoscopic radiofrequency ablation with Barrx 360 express RFA cathether
    • 2020-06-30 Right side tonsil tumor, wide excision; Mouth floor tumor, above wharton’s duct, excision
  • radiotherapy
    • 2021-10-06 ~ 2021-10-29 RT to the Rt neck LAPs and tonsilar tumor: 36 Gy/ 18 fx
    • 2020-08-06 ~ 2020-09-09 RT to the bil. neck, Rt tonsil, LAPs: 50y/ 25fx. The whole esophagus and adjacent lymphatic drainage area: 45y/ 25fx.
  • chemotherapy
    • 2022-07-22 - docetaxel 40mg/m2 59mg 1hr + cisplatin 40mg/m2 59mg 2hr + fluorouracil 1000mg/m2 2980mg 46hr
    • 2022-06-27 - docetaxel 40mg/m2 59mg 1hr + cisplatin 40mg/m2 59mg 2hr + fluorouracil 1000mg/m2 2980mg 46hr
    • 2022-06-02 - docetaxel 40mg/m2 58mg 1hr + cisplatin 40mg/m2 58mg 2hr + fluorouracil 1000mg/m2 2900mg 46hr
    • 2022-05-18 - docetaxel 40mg/m2 58mg 1hr + cisplatin 40mg/m2 58mg 2hr + fluorouracil 1000mg/m2 2900mg 46hr
    • 2022-04-29 - docetaxel 40mg/m2 59mg 1hr + cisplatin 40mg/m2 59mg 2hr + fluorouracil 1000mg/m2 2990mg 46hr
    • 2022-04-14 - docetaxel 40mg/m2 58mg 1hr + cisplatin 40mg/m2 58mg 2hr + fluorouracil 1000mg/m2 2920mg 46hr (cisplatin 40 <- 50)
    • 2022-03-17 - docetaxel 40mg/m2 60mg 1hr + cisplatin 50mg/m2 79mg 2hr + fluorouracil 3170mg/m2 2920mg 46hr (TPF - https://pubmed.ncbi.nlm.nih.gov/20878112/ for head and neck cancer)
    • 2021-11-03 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2021-10-25 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2021-10-18 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2021-10-07 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2020-09-01 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2020-08-25 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2020-08-18 - cisplatin 40mg/m2 60mg 2hr (CCRT)
    • 2020-08-11 - cisplatin 40mg/m2 60mg 2hr (CCRT)

==========

2022-08-23

  • Weight loss 17 kgw during the past 6 months (2022-08-22 37 kgw <- 2022-03-14 54 kgw), 173 cm, BMI = 12.4 kg/m2, severe thinness. The patient has a history of alcoholism, malnutrition and hypomagnesemia are suspected. NAKO NO.5 has been prescribed.
  • Hyperuricemia is observed (2022-08-22 blood uric acid 9.3 mg/dL), Euricon (benzbromarone 50mg/tab) 1# QD might be considered.

2022-06-06

  • The patient was diagnosed with stage IVB esophageal cancer in June 2020, and he underwent partial CCRT in September of the following year. Following the last dose of cisplatin received at the beginning of November of 2021, the patient started receiving TPF on 2022-03-17.
  • Last images in March 2022 revealed mild mucosal thickening in the right palatine fossa, and the lesions in the lower T-spine and some L-spine areas have remained stationary, An update image studye might be helpful.
  • A steady rise in the CEA level has been observed:
    • 2022-04-28 10.607 ng/ml
    • 2022-02-23 4.299 ng/ml
    • 2021-12-01 3.934 ng/ml
    • 2020-08-11 2.202 ng/ml
  • Hypomagnesia has been noted since 2020-05, possibly caused by undernutrition (BMI 15), electrolyte supplements may be beneficial (MgO 500g PO BID and Nako No.5 500mL IVD BID have been prescribed).

2022-05-19

  • This patient was diagnosed with stage IVB esophageal cancer, he had surgery in June, July 2020, and incomplete CCRT the following September. After receiving the last dose of cisplatin in early November of 2021, the patient began receiving TPF on 2022-03-17.
  • Images in March 2022 revealed mild mucosal thickening in the right palatine fossa, and the lesions in the lower T-spine and some L-spine areas have remained stationary. A slow pace of progress might be likely?
  • CEA level continues to rise steadily, lab data:
    • 2022-04-28 10.607 ng/ml
    • 2022-02-23 4.299 ng/ml
    • 2021-12-01 3.934 ng/ml
    • 2020-08-11 2.202 ng/ml
  • Records available in the hospital indicated that blood magnesium levels were almost always below the lower limit of normal. He was found to have been an alcohol dependent for years. The patient with BMI 15 (height of 175 cm, weight of 46 kg) might be undernourished. It is common to observe hypomagnesemia in patients suffering from alcoholism and malnutrition. The need for a lifestyle change cannot be overstated.
  • The components of the current regimen contain 5-Fu and cisplatin, which might also cause a low magnesium level. If hypomagnesemia becomes symptomatic, MgSO4 injection might be considered.

2022-04-29

  • After receiving last cisplatin in early November of 2021, this patient began receiving TPF from 2022-03-17.
  • Lab data results: serum Mg 1.2 mg/dL (2022-04-28), CEA 10.607 ng/ml (2022-04-28) <- 4.299 (2022-02-23) <- 3.934 (2021-12-01) <- 2.202 (2020-08-11).
  • CEA is increasing in trend, which needs to be addressed.
  • Hypomagnesemia is frequently a result of magnesium depletion, which is often caused by gastrointestinal or renal losses.
    • One of the main dose-limiting side effects of fluoropyrimidines such as FU (and its oral prodrugs capecitabine and ftorafur-uracil [UFT]) is diarrhea.
    • It is also possible that renal loss could be caused by medications such as diuretics (loop and thiazide), antibiotics (aminoglycoside, amphotericin, pentamidine), calcineurin inhibitors, cisplatin, antibodies targeting epidermal growth factor (EGF) receptors (cetuximab, panitumumab, matuzumab), which are not prescribed currently. (5-FU and cisplatin are in recent regimen.)
    • Alcoholism is also a cause of renal loss. According to the consultation with mental health clinic 2020-05-30, the patient might be alcohol dependent.
    • The use of MgSO4 injection might be considered if there are no contraindications.

700929934

220819

{DLBCL stage IV}

  • exam finding
    • 2022-06-06 Automated perimetry
      • clinical diagnosis: glaucoma
      • Report: VF on 06/06/2022 (od) tunnel vision only (os) arcuate scotoma, MD -26.03/-6.48 dB
    • 2022-06-02 CT - abdomen, pelvis
      • Finding
        • Some enlarged LNs at retroperitoneum along aorta and IVC.
        • Wall edema of rectum.
        • A small cystic lesion (0.6cm) at pancreatic tail.
        • A calcified nodule (0.5cm) at RML. Right minimal pleural effusion.
        • Gallbladder stones (2-6mm).
        • Atherosclerosis of aorta, iliac arteries.
      • IMP:
        • Some enlarged LNs at retroperitoneum along aorta and IVC suspected lymphoma.
        • Gallbladder stones (2-6mm). Wall edema of rectum.
    • 2022-05-24 Patho - bone marrow biopsy - negative for malignancy
      • Bone marrow, iliac, clinically: DLBL, biopsy — Negative for malignancy.
      • IHC stains: CD3: <2%; CD20: <2 %; bcl-2: <2%, bcl-6: (-); MUM-1: (-) (of the nucleated cells).
      • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • 2022-05-21 CT - brain
      • Brain atrophy
    • 2022-05-21 Micro-sonography
      • glaucoma od > os
      • 229/224um, no sub RPE infiltration ou
      • 54/82um, VCDR 0.82/0.58, IS thining
      • GCC loss od
    • 2022-05-21 Optical Coherence Tomography
      • c/d: 0.9 od, 0.4 os, media clear, no infiltration noted ou
    • 2022-05-18 Whole body PET scan
      • Glucose hypermetabolism in lymph nodes from head to bilateral upper thighs, compatible with lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      • Glucose hypermetabolism in the left upper lung pleura, right lower lung, left lobe of the liver, spleen, several C-, T- and L-spine, sacrum, and bilateral iliac bones, highly suspected lymphoma with diffuse involvement of multiple extralymphatic organs.
      • Diffuse large B-cell lymphoma, stage IV (AJCC, 8th ed.), by this F-18 FDG PET scan.
    • 2022-05-16 CXR
      • Boderline cardiomegaly
      • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-05-10 Patho - lymph node region resection
      • Lymph node, right level Ib, excisional biopsy — Diffuse large B-cell lymphoma
      • Histology type: diffuse large B-cell lymphoma with atypical large lymphoid cells with nucleoli and totally effacement of nodal architecture
      • Immunohistochemistry: CK(-), CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+, focal), C-MYC(-, <30%) , Ki-67: 80% for tumor
    • 2022-05-06 CT - neck
      • Finding
        • Multiple enlarged, homogeneously enhancing lymph nodes at bilateral level I, II, III, IV, V, as well as bilateral mediastinum. There are multiple enlarged lymph nodes in bilateral parotid glands as well. Lymphoma should first be considered.
        • Bilateral symmetric pharyngeal mucosa.
        • Normal size and normal enhancement pattern of bilateral submandibular glands.
      • Impression
        • Consider lymphoma. Suggest further evaluation.
    • 2022-05-05 Nasopharyngoscopy
      • smooth NPx, OPx, HPx
    • 2017-10-12 Pure Tone Audiometry, PTA
      • R’t: mild to profound mixed type HL
      • L’t: mild to severe mixed type HL
  • lab data
    • Anti-HBc 2022-05-21 Reactive, 8.51 S/CO
    • HBsAg 2022-05-16 Reactive, 4785.50 S/CO
    • Anti-HCV 2022-05-16 Nonreactive 0.07 S/CO
  • consultation
    • 2022-05-20 Ophthalmology
      • Objective
        • BV of right eye > left eye for over 1 year
        • recently diagnosed DLBCL with initial presentation of bilateral sunmadibular gland enlargement
        • phx: DM, HTN under bokey
        • ophx: glaucoma under combigan for 1 year
        • BCVA OD 0.3(0.5x+0.75/-2.0x85) OS 0.5(0.6x+1.25/-0.75x75)
        • PT: 20/19 mmHg
        • pupil: 3.5 mm+/+, 3mm+/+, rapd + od
        • EOM: full and free
        • Lid: lago os , imcomplete blinjing os
        • conj: pterygium at 3 o’c od, np os
        • K: cl od, inf spk os
        • AC: deep and clear ou
        • Lens: NS 2+ OD>OS
        • F’d: c/d: 0.9 od, 0.4 os, media clear, no infiltration noted ou
      • Assessment:
        • glaucoma od > os
        • lagophthalmos os due to left CN 7 palsy
      • Plan
        • combigan 1gtt bid ou + sinomin 1gtt qid os + duratears qid os
        • we will arrange OCT and VF later for optic neuropahty od
  • chemoimmunotherapy
    • 2022-07-29 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1378mg 30min D2 + doxorubicin 50mg/m2 91mg 30min D2 + prednisolone 60mg/m2 5mg/tab 11tab BID D2-6 (R-CHOP, vincristine not avaliable then)
    • 2022-07-07 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1378mg 30min D2 + doxorubicin 50mg/m2 91mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 11tab BID D2-6 (R-CHOP)
    • 2022-06-16 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1378mg 30min D2 + doxorubicin 50mg/m2 91mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 11tab BID D2-6 (R-CHOP)
    • 2022-05-25 - rituximab 375mg/m2 690mg 8hr D1 + cyclophosphamide 750mg/m2 1380mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-4 (R-COP)

==========

2022-08-19

  • TPR, BP were stable during this hospital stay.
  • Blood sugar 2022-08-18 17:10 236 mg/dL, 2022-08-19 08:21 249 mg/dL. If diabetes is confirmed, since the patient has normal kidney function (based on 2022-08-18 laboratory results), then metformin 500mg BID could be considered.

2022-05-30

  • Diffuse large B-cell lymphoma involving both sides of the diaphragm, stage IV (PET 2022-05-18), no evidence of involvement of the central nervous system yet (CT 2022-05-21).
  • BCL2(+), BCL6(+), however C-MYC less than 30% (pathology 2022-05-10), might not be regarded as a ‘double/triple hit’ lymphoma. LDH 384U/L, anti-HBc reactive (2022-05-21), HBsAg reactive (2022-05-16). No anti-HBs, IgM anti-HBc, Epstein-Barr virus results were found.
  • RCHOP might be indicated in patients with DLBCL. For patients who are too frail to withstand even R-mini-CHOP, treatment with a systemic steroid, with or without rituximab, might improve the patient’s performance status (PS) and enable subsequent treatment with R-mini-CHOP or single chemotherapeutic agents.
    • S-GPT/ALT, S-GOT/AST were both slightly elevated (2022-05-20). Cyclophosphamide, doxorubicin, and vincristine dosages may need to be adjusted for preexisting liver dysfunction (not applicable to this patient at present).
    • As the patient has ‘Three Hypers’ and borderline cardiomegaly as well as increased interstitial lines in both lungs (CXR 2022-05-16), decreased cardiopulmonary function could be expected. LVEF should be evaluated prior to initiation of RCHOP. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation.
  • HBsAg(+), anti-HBc(+), elevated ALT, AST levels suggest infection with HBV. Antiviral prophylaxis might be considered prior to initiating rituximab treatment.
  • HR (102 -> 65 pulse/min) and SBP (142 -> 92mmHg) have fallen sharply 2022-05-23 08:45 which should be addressed. Amlodipine and/or valsartan might be temporarily suspended.

701196422

220817

  • exam finding
    • 2022-08-17 CXR
      • Bilateral pleural effusion.
      • Ground glass opacities in bil. lungs.
      • Normal appearance of trachea and bil. main bronchus.
      • Intact bony structure(s).
    • 2022-08-16 MRI - brain
      • Multiple bilateral cerebellar, cerebral and left upper brain stem metastases, with slight regression in cerebelli and cerebral hemispheres, but seems stationary or mild progression in left upper brain stem when compared with 2022/06/07 MRI.
    • 2022-08-16 SONO - chest
      • symptom: dyspnea
      • indication: effusion
      • clinical diagnosis
        • right breast ca
        • bilateral pleural effusion
      • Echo Diagnosis
        • Left thorax: moderate amount pleural effusion s/p drainage of 860 cc, serosanguinous pleural effusion.
        • Right thorax: small amount pleural effusion; thoracocentesis was not performed due to high risks of complications.
    • 2022-08-15 CXR
      • Bilateral pleural effusion.
      • Ground glass opacities in bil. lungs.
      • Normal appearance of trachea and bil. main bronchus.
      • Compression fracture of T12.
    • 2022-08-15 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (30.9 - 11.9) / 30.9 = 61.49%
        1. Normal AV with no AR
        1. Normal MV with mild MR
        1. Normal LV chamber size and wall thickness
        1. Preserved LV and RV systolic function
        1. No PR, trivial TR, normal IVC size
        1. Large amount of left pleural effusion, right side deviation of heart and poor para-sternal window
    • 2022-07-25 CXR
      • Bilateral pleural effusion.
      • Focal calcification of left pleura.
      • Compression fracture of spine.
      • Normal appearance of trachea and bil. main bronchus.
      • Ground glass opacities in bil. lungs.
    • 2022-07-25 SONO - chest
      • Echo diagnosis: Bilateral pleural effusion (Left: small and Right: small to moderate), post left diagnostic thoracentesis and bilateral therapeutic thoracentesis.
    • 2022-07-04 CXR
      • Bilateral pleural effusion.
      • Ground glass opacities in bil. lungs.
      • Multiple nodules at bil. lungs.
      • Compression fracture of spine.
    • 2022-07-04 SONO - chest
      • Echo diagnosis: Bilateral pleural effusion (Left: minimal and Right: moderate to massive), s/p right diagnostic and therapeutic thoracentesis.
    • 2022-06-13 SONO - chest
      • Echo diagnosis: Bilateral pleural effusion (Left: minimal to small and Right: moderate to massive), post right diagnostic and therapeutic thoracentesis.
    • 2022-06-07 MRI - brain
      • Clinical information: Lt breast advanced ca with spine mets
      • DCIS (Ductal Carcinoma in Situ) was told after CNB (core needle biopsy) at Taipei Medical University Hospital on 2015-08-11 without treatment.
      • Findings:
          1. Numerous intra-axial faintly enhancing lesions with perifocal edema in bilateral cerebral and cerebellar hemispheres, and midbrian and brain stem, with the largest one about 20 mm at right occipital lobe. Increased in size and number of these metastatic lesions, as compared with MRI on 20220302.
          1. Multifocal peritumoral edema.
    • 2022-06-02 SONO - abdomen
      • Gallbladder stones (0.37-0.99cm).
      • Splenomegaly.
      • Right pleural effusion.
    • 2022-06-02 CT - lung/mediastinum/pleura
      • Residual breast tumor at right side with lung meta, bone mets, stationary.
      • Bilateral massive pleural effusion.
    • 2022-04-18 CXR
      • Bilateral pleural effusion.
      • Normal appearance of trachea and bil. main bronchus.
      • Compression fracture of T12.
      • Ground glass opacities in bil. lungs.
    • 2022-03-11 CT - lung/mediastinum/pleura
      • Compatible with breast cancer with lung and bone mets, the lung mets is stationary.
      • Bilateral pleural effusion with stationary extension.
    • 2022-03-11 SONO - abdomen
        1. Prior sonography identified An ill-defined hypoechoic lesion 3.19 cm in S7 liver is noted again, mild decreasing in size to 2.86 cm. Follow up is indicated.
        1. Several gallstone are noted.
        1. The spleen shows enlarged in size (long axis: 13.2 cm).
    • 2022-03-02 MRI - brain
      • C/W multiple brain metastases, progressive change as compared with MRI on 20211108.
    • 2022-01-24 CXR
      • Lung markings: opacification in the bilateral lower lung fieldl small nodular lesions in the bilatearl lung fields.
      • blurred bilateral hemidiaphrams
      • blunting bilateral costophrenic angles
    • 2022-01-24 Neck
      • increased density in the C2 vertebral body. Nature?
    • 2022-01-24 Nasopharyngoscopy
      • Multiple petechiae were found at posterior pharyngeal wall and arytenoid
      • No active bleeder and foreign body was found
    • 2021-12-23 CT - abdomen
      • S/P left breast operation.
      • Multiple bony metastases.
      • Some nodules at bil. lungs. Bil. pleural effusions.
      • Splenomegaly.
    • 2021-12-06 SONO - abdomen
        1. Irregular hypoechoic lesion, 3.19x2.68cm in S7 liver, progression.
        1. GB stone.
    • 2021-12-02 Patho - intradermal nervus
      • Skin, trunk, total excision — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67 (30%), GATA-3 (+).
      • Section shows skin tissue with irregular neoplastic ducts infiltration. Margins free (0.1 cm from closest side margin and 0.3 cm from deep margin.
    • 2021-11-08 MRI - brain
      • C/W multiple brain metastases, regression in sizi and number as compared with MRI on 20210508, but with progressive white matter edema in right posterior temporal-occipital lobe.
    • 2021-09-24 CT - abdomen
        1. Multiple bony metastases.
        1. Flow artifact in S7 liver.
        1. Splenomegaly and a hemangioma 1.2 cm in the spleen.
    • 2021-08-31 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20200908, some new bone lesions are noted and some previous bone lesions are more evident. The scintigraphic findings suggest multiple bone metastases in progression.
    • 2021-08-31 SONO - abdomen
        1. Prior sonography identified An ill-defined hypoechoic lesion 2.48 cm in S7 liver is noted again, mild decreasing in size to 2.18 cm. Follow up is indicated.
        1. A gallstone 1.45 cm is suspected.
        1. The spleen shows enlarged in size (long axis: 13.35 cm).
    • 2021-08-03 MRI - brain
        1. Brain metastases, slight regression in right hippocampus, bil. cerebellar hemispheres and left IAC.
        1. Seems stationary of bil. cerebral nodules.
    • 2021-06-08 CT - lung
      • breast ca with lung, pleura, and bones metastasis, in regression of pleural effusion and stationary of lung and bony metastases as compared with previous CT study 2021/03/22
    • 2021-06-08 SONO - abdomen
        1. An ill-defined hypoechoic lesion 2.48 cm in S7 liver is noted that may be tumor or pseudolesion? Please correlate with contrast enhanced dynamic CT or MRI.
        1. A gallstone 1.79 cm is suspected.
        1. The spleen shows prominence in size (long axis: 11.38 cm).
    • 2021-05-08 MRI - brain
      • Brain metastases, progression in right hippocampus, bil. cerebellar hemispheres and left IAC.
    • 2021-03-22 SONO - breast
        1. Right breast tumors, suspected malignancy with axillary lymph node metastasis.
        1. Right breast skin thickening.
        1. Left breast tumor, suspected fibroadenoma. Suggest follow up.
      • BI-RADS 6. known biopsy-proven malignancy
    • 2021-03-22 CT - lung
      • breast ca with lung, pleura, and bones metastasis, in prgression of lung and pleural metastases as compared with previous CT study 2020/12/22
    • 2021-01-27 MRI - brain
      • multiple brain metastasis, decrease in sizes and numbers.
    • 2020-12-22 CT - lung
      • breast ca with lung, pleura, and bones metastasis, stationary of as compared with previous CT study 2020/09/11.
    • 2020-10-28 MRI - brain
      • multiple brain metastasis, increase in sizes and numbers.
    • 2020-09-11 CT - lung
      • Compatible with left breast cancer with lung and bone mets.
      • Enhanced breast nodules at right side, in regression.
    • 2020-09-08 Tc-99m MDP whole body bone scan
      • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2019/09/27, most of the previous bone lesions are less evident except some bone lesions in the left S-I joint and right femur are a little more evident.
    • 2020-08-06 T-L spine AP+ Lat.
      • Pathologic compression fracture of T8,9,12, and L1,5
      • Blastic metastasis of bony structures
    • 2020-07-22 MRI - brain
      • multiple brain metastasis, decrease in sizes and numbers.
    • 2020-06-19 CT - lung
      • Compatible with breast cancer over both sides with lung, bone meta and pleural effusion. The main mass at left breast and right bresat tumors decreased in size.
      • The lung meta regressed.
    • 2020-06-19 SONO - abdomen
      • A hypoechoic nodule (1.59x1.66cm) at S7 of liver.
      • Gallbladder stones (0.51-0.92cm).
      • Splenomegaly.
    • 2020-06-19 SONO - breast
      • Left breast cancer
      • Bil. fibroadenomas
      • Suspected right breast tumor (#1)
    • 2020-04-20 MRI - brain
      • Numerous brain metastases.
    • 2020-03-11 CT - lung
      • breast ca with lung, pleura, and bones metastasis, in regression of lung metastasis and primary tumors, but in progression of bones metastasis as compared with previous CT study.
    • 2020-03-03 2D transthoracic echocardiography
        1. Normal chamber size
        1. Normal LV and RV contractility
        1. Mitral valve prolapse, mild MR
        1. Mild TR
    • 2020-03-03 SONO - abdomen
      • Fatty liver, mild to moderate
      • Suspect focal liver lesion or fatty liver related change, S7/8
      • Gall stone
      • Splenomegaly
      • Bilateral pleural effusion
    • 2019-10-31 CXR
      • Ground glass opacities in bil. lungs.
      • Bilateral pleural effusion.
    • 2019-10-27 CXR
      • Diffuse nodules in bilateral lungs.
      • Consolidations in bilateral lungs.
      • Progression of right pleural effusion as compare with CXR on 2019-10-22.
      • No cardiomegaly.
      • Compression fractures at lower T-spine.
    • 2019-10-22 CXR
      • Ground glass opacities and nodules in bil. lungs.
    • 2019-10-21 CXR
      • Presence of nodules at bil. lungs
      • Bilateral pleural effusion.
    • 2019-10-04 M-mode Echo
      • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 25) / 80 = 68.75%
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Limited echo window due to breast Ca wound
    • 2019-10-01 Whole body PET scan
        1. The FDG PET findings are compatible with left breast malignancy with right breast, multiple lung, liver, bone and lymph node metastases as mentioned above. Please correlate with other clinical findings for further evaluation.
        1. A small focal area of increased FDG uptake in the left hemisphere of the cerebellum. A metastatic lesion can not be ruled out.
    • 2019-09-27 Tc-99m MDP whole body bone scan
      • The scintigraphic findings suggest multiple bone metastases.
    • 2019-09-26 CT - lung
      • Left breast cancer with skin invasion.
      • Mediastinal lymphadenopathy and right breast, diffuse bone and lung mets.
    • 2019-09-24 MRI - T-spine
      • Findings
          1. Mild scoliosis of thoracicolumbar vertebral column.
          1. Diffuse osteolytic lesions with abnormal soft tissue intensity and compression involving T2-12 and L1-4 vertebral bodies (visible in these images), with collapse of T3 and T12 vertebral body, and compromise of neuroforamina at T11-T12-L1 levels.
      • Imp:
        • Diffuse bony and lung metastases as aforementioned.
  • consultation
    • 2022-08-14 Neurology
      • Q
        • no blurred vision aura before visual defect, seeing things white, lasts 30 minutes and recovered spontaneously
      • A
        • This 43 y/o woman has a history of breast cancer with bone and brain metastatsis. She complained of left visual field defect noted since this morning. The symptom may fluctuate but the patient claimed that she may not pay attention to it. Frequent dizziness was also noted for a few days. I was consulted for further evaluation.
        • O
          • NE E4V5M6 cachexia
          • CNs: left homonymous hemianopia
          • MP: >4
          • sensation: intact
          • FNF: no dysmetria
          • brain MRI in 2022/06: multiple metastases, bilateral occpital lobes involvement and right side worse
        • impression:
          • visual field defect caused by metastatses
        • suggestion:
          • control underlying disease progression
          • neurology OPD follow-up for EEG and VEP study
          • consider antiseizure medication after evaluation or clinical seizure witnessed.
    • 2022-08-14 Ophthalmology
      • Q
        • no blurred vision aura before visual defect, seeing things white, lasts 30 minutes and recovered spontaneously
      • A
        • S: Left homonymous side photopsia for 2-3 hrs, painless, with persistent left VF defect now
          • Deneid fever
          • Lab data : pancytopenia
          • phx: breast caner with lung, bone, liver, LN, skin and brain mets with right occipital lobe involved
          • ophx: denied
          • nka
        • O:
          • VAcNC: OD 20/70 OS 20/100
          • IOP:14/16mmHg
          • pupil: 3mm+/+, 3mm+/+, no rapd
          • EOM: full and free
          • Confrontation test: left homonymous hemianopia
          • Red desaturation test: intact ou
          • conj: np ou
          • K: cl ou
          • AC: shallow/clear ou
          • Lens: cl ou
          • fundus : c/d: 0.7 margin clear, vessels perfusion ok, no break ou
        • A:
          • Left homonymous hemianopia c/w brain metastasis with right occipital lobe
        • P:
          • Control underlying disease + correct pancytopenia
          • Consider further brain image as your expertise
          • oph opd f/u for VF if condition stable, if bv/pain/neurologic defect/any symptom worsen, come back earlier
    • 2022-03-19 Ophthalmology
      • Q
        • Patient complained of suspected glaucoma at our ophthalmic clinic and would like to seek expertise from ophthalmic doctor.
      • A
        • S: left homonymous side photopsia and transient vision loss recently, and prolonged duration today, improving now
        • O
          • phx: breast ca with brain mets with right occipital lobe involved
          • ophx: enlarged cupping ou
          • BCVA: OD 0.4(0.8x0/-1.0x95) OS 0.6(1.0x-0.25/-0.5x70)
          • PT: 16/14 mmHg
          • pupil: 3mm+/+, 3mm+/+, no rapd
          • EOM: full and free, nystagmus in lateral gaze ou with fast pahse to lateral
          • confrontation test: inf temp VFD os?
          • conj: np ou
          • K: cl ou
          • AC: shallow/clear ou
          • LEns: cl ou
          • c/d: 0.7 inf notch od?, margin clear
        • A:
          • favor occipital seizure
        • P:
          • explain current condition and no fundus exam due to shallow AC to the patient, opd f/u for OCT and VF test(111/4/18) for preglaucoma and occipital lobe mets
          • if the symptoms prolong or persist, if any neurologic sign show up, come back eariler
          • opd f/u on W2
    • 2022-01-24 ENT
      • Q
        • CC.hemoptysis one time this morning
        • foreign body sensation in throat
        • throat pain(-), dizziness(-)
        • Onset: ate drug
        • Px. breast cancer under therapy treatment
        • TOCC: nil
        • vaccine: denied
      • A
        • Subjective:
          • hemoptysis one time this morning
          • foreign body sensation in throat
          • No hemoptysis and lump sensation now.
        • Scope:
          • Multiple petechiae were found at posterior pharyngeal wall and arytenoid
          • No active bleeder and foreign body was found
      • Plan:
        • Treat her thrombocytopenia as your expertise
        • Please give Broen-C TID
    • 2020-10-24 ENT
      • Q
        • fever for 3 days with sore throat and greenish rhinorrhea
        • denied chest pain, SOB, abd pain, diarrhea, dysuria
      • A
        • Water’s view: fluid accumulation over bilateral maxillary sinuses.
        • Local finding: no neck tenderness; fair mouth opening; no enlarged tonsils; injected posterior oropharyngeal wall; erythematous abrasive change over philtrum; yellowish crust with some blood clot in bilateral nasal cavity.
        • Scope: blood clot with yellowish mucus discharge over bilateral nasal cavity with post-nasal dripping; erosive change over nasopharynx, suspect post-RT change; smooth oropharynx and hypopharynx, erythematous change of epiglottis; patent airway; sputum noted in trachea.
        • Impression: acute nasopharyngitis and acute sinusitis, suspected pneumonia.
      • Plan:
        • Suggest admission to department of infecious disease or oncology for intravenous antibiotic treatment.
        • Please prescribe Broen-C, cough mixture, allegra, and biomycin ointment (for the philtrum wound) as symptomatic treatment.
        • Culture of nasal discharge was done.
  • chemotherapy
    • 2022-08-16 - Enhertu (fam-trastuzumab deruxtecan-nxki) 5.4mg/kg 200mg 90min
    • 2022-07-25 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
    • 2022-07-04 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
    • 2022-06-13 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2022-05-23 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2022-05-02 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2022-04-11 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2022-03-16 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2022-02-23 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2022-01-19 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
    • 2021-12-29 - Kadcyla (ado-trastuzumab) 120mg 90min
    • 2021-11-29 - Kadcyla (ado-trastuzumab) 3.6mg/kg 100mg 90min
    • 2021-10-27 - Kadcyla (ado-trastuzumab) 3.6mg/kg 120mg 90min
    • 2021-09-08 - Kadcyla (ado-trastuzumab) 3.6mg/kg 150mg 90min
    • 2021-08-18 - Kadcyla (ado-trastuzumab) 150mg 90min
    • 2021-07-28 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-07-07 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-06-16 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-05-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-05-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-04-14 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-03-24 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-03-03 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-02-10 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2021-01-20 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-12-30 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-12-09 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-11-18 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-10-27 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-10-07 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-09-16 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-08-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-08-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-07-15 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-06-24 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-06-03 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-05-06 - Herceptin (trastuzumab) 600mg SC 5min
    • 2020-04-15 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-03-25 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr
    • 2020-03-04 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr + docetaxel 60mg/m2 82mg 1hr + carboplatin AUC 6 300mg 2hr
    • 2020-02-03 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr + docetaxel 60mg/m2 80mg 1hr + carboplatin AUC 6 300mg 2hr
    • 2020-01-06 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg IVD 1hr + docetaxel 75mg/m2 100mg 1hr + carboplatin AUC 6 300mg 2hr

[assessment]

  • During this hospitalization, the patient is receiving her first dose of Enhertu.
  • 2022-08-15 2D transthoracic echocardiography prior to having Enhertu showed baseline LVEF = (LVEDV - LVESV) / LVEDV = (30.9 - 11.9) / 30.9 = 61.49%
  • Hypoalbuminemia is observed (2022-08-17 2.4 g/dL, normal 3.5 ~ 5.7). For humans, deruxtecan plasma protein binding is approximately 97% and the blood-to-plasma ratio is approximately 0.6, in vitro. Low albumin might potentially increase unbound deruxtecan concentration.
  • Enhertu is classified as having a moderate emetic risk according to the NCCN guidelines, premedication palonosetron has been administered as the antiemetic agent.
  • Recommended antiemetics for days 2-4: (reference: Rugo HS, Bianchini G, Cortes J, Henning JW, Untch M. Optimizing treatment management of trastuzumab deruxtecan in clinical practice of breast cancer [published online ahead of print, 2022 Aug 11]. ESMO Open. 2022;7(4):100553. doi:10.1016/j.esmoop.2022.100553 )
    • 1st cycle:
      • dexamethasone 4mg or 8mg daily +- metoclopramide 10mg PO TID or
      • 5-HT3 RA [e.g. granisetron (1-2 mg PO QD or 0.1 mg/kg IV QD)]
    • Subsequent cycles:
      • If adequate, repeat above.
      • If not (e.g. grade >= 1 for >= 3 days), give
        • aprepitant (80mg PO) + 5-HT3 RA +- dexamethasone (8mg) or
        • dexamethasone (8mg QD) +- metoclopramide (10mg PO TID)

700887906

220816

  • lab data
    • Creatinine
      • 2022-07-22 Creatinine 2.24 mg/dL
      • 2022-07-15 Creatinine 2.53 mg/dL
      • 2022-07-12 Creatinine 4.16 mg/dL
      • 2022-06-21 Creatinine 2.03 mg/dL
      • 2022-05-30 Creatinine 2.20 mg/dL
      • 2022-05-09 Creatinine 1.69 mg/dL
      • 2022-04-30 Creatinine 2.07 mg/dL
      • 2022-04-27 Creatinine 1.98 mg/dL
      • 2022-04-21 Creatinine 1.49 mg/dL
      • 2022-04-18 Creatinine 1.75 mg/dL
      • 2022-04-16 Creatinine 3.63 mg/dL
      • 2022-04-15 Creatinine 3.95 mg/dL
      • 2022-04-14 Creatinine 2.33 mg/dL
      • 2022-04-12 Creatinine 1.86 mg/dL
      • 2022-02-28 Creatinine 1.81 mg/dL
      • 2022-02-15 Creatinine 1.65 mg/dL
      • 2021-11-10 Creatinine 1.93 mg/dL
      • 2021-09-23 Creatinine 2.35 mg/dL
      • 2021-07-08 Creatinine 2.21 mg/dL
      • 2021-04-08 Creatinine 1.77 mg/dL
      • 2021-01-11 Creatinine 2.05 mg/dL
      • 2020-11-05 Creatinine 1.74 mg/dL
      • 2020-09-01 Creatinine 1.7 mg/dL
      • 2020-08-21 Creatinine 2.1 mg/dL
      • 2020-08-20 Creatinine 2.2 mg/dL
      • 2020-08-14 Creatinine 3.1 mg/dL
      • 2020-08-12 Creatinine 2.2 mg/dL
      • 2020-08-04 Creatinine 1.8 mg/dL
      • 2020-07-10 Creatinine 1.7 mg/dL
      • 2020-06-15 Creatinine 1.7 mg/dL
      • 2020-06-15 Creatinine 1.7 mg/dL
      • 2020-05-29 Creatinine 1.9 mg/dL
      • 2020-04-11 Creatinine 1.8 mg/dL
      • 2020-04-09 Creatinine 1.6 mg/dL
      • 2020-02-14 Creatinine 1.5 mg/dL
      • 2020-02-07 Creatinine 1.4 mg/dL
      • 2020-02-04 Creatinine 1.4 mg/dL
      • 2020-01-07 Creatinine 1.5 mg/dL
  • exam findings
    • 2022-07-22 ECG
      • Sinus rhythm with 1st degree A-V block
    • 2022-07-19 MRI - liver, spleen
      • Multiple liver tumors suspected metastases.
      • S/P left nephrectomy. S/P right PCN.
      • A soft tissue nodule (1.5cm) at umbilical region suspected tumor seeding.
      • Some LNs at retroperitoneum.
    • 2022-07-15 CT - abdomen, pelvis
      • Multiple liver tumors suspected metastases.
      • S/P left nephrectomy and cystectomy. S/P right PCN.
      • A soft tissue nodule (1.5cm) at umbilical region suspected tumor seeding.
      • Some LNs at retroperitoneum.
    • 2022-07-15 KUB
      • S/P right pig-tail catheter indwelling.
    • 2022-07-12 ECG
      • Sinus rhythm with 1st degree A-V block
    • 2022-05-30 KUB
      • S/P PCN catheter drainage, right side.
      • Lumbar spondylosis.
    • 2022-05-30 CXR
      • Increased bilateral lung markings.
    • 2022-05-21 CT - abdomen, pelvis
        1. S/P left nephrectomy and cystectomy. S/P PCN drainage, right side.
        1. Enlarged lymph nodes in right lower abdome around IVC, suspected metastatic lymph nodes.
    • 2022-05-20 SONO - nephrology
      • s/p left nephrectomy
    • 2022-05-09 PD-L1 (SP142)
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
        • Tumor type: Infiltrating urothelial carcinoma, high-grade
        • Tumor location: Prostate
        • Testing assay: SP142 Assay (Ventana)
        • Testing platform: BenchMark ULTRA
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
        • Control slide result: [ V ] Pass, [ ] Fail
        • Adequate tumor cells present (>=50 viable tumor cells): [ V ] Yes, [ ] No
      • Result:
          1. Tumor cell (TC) staining assessment:
            1. TC category: TC < 1%
            1. Percentage of PD-L1 expressing tumor cells (%TC): < 1% (optional)
          1. Tumor-infiltrating immune cell (IC) staining assessment:
            1. IC category: IC < 1%
            1. Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): < 1% (optional)
      • Note:
          1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
          1. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-04-15 Patho - urinary bladder partial/total resection
      • PATHOLOGIC DIAGNOSIS:
          1. Urinary bladder, Robotic-assisted radical cystoprostatectomy ( s/p TURBT) — Urothelial carcinoma in situ — No residual papillary urothelial carcinoma
          1. Prostate, RARC — Involved by infiltrating urothelial carcinoma, high-grade (at prostatic stroma) — Positive for tumor at apex margin
        • 3, Seminal vesicles, bilateral, RARC — Negative for malignancy
          1. Ureter, right, RARC — Negative for malignancy
          1. Ureter, left, RARC — Negative for malignancy
          1. Lymph node, right common iliac, dissection —- Negative for malignancy (0/1)
          1. Lymph node, right internal iliac, dissection —- Negative for malignancy (0/2)
          1. Lymph node, left external iliac, dissection —- Negative for malignancy (0/1)
          1. Lymph node, rleft external iliac, dissection —- Negative for malignancy (0/3)
          1. Vas deferens, left, RARC — Negative for malignancy
          1. Vas deferens, right, RARC — Negative for malignancy
          1. AJCC 8th edition Pathology stage: pT4aN0(if cM0); AJCC pathologic stage IIIA
      • MICROSCOPIC EXAMINATION (for urinary bladder):
          1. Histological type, Urothelial: Papillary urothelial carcinoma, invasive
          1. Histological grade: For urothelial carcinoma, other variants, or divergent differentiation: High grade
    • 2022-04-13 2D transthoracic echocardiography
      • Normal chamber size
      • Thickening of IVS
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with trivial AR, mild MR, TR and PR
      • No regional wall motion abnormalities
    • 2022-04-12 ECG
      • Sinus rhythm with 1st degree A-V block
    • 2022-04-08 Tc-99m MDP whole body bone scan with SPECT
        1. In comparison with the previous study on 2020/08/18, the lesions in the middle and lower C-spines are a little more evident. Degenerative change in a little more severe status may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
        1. No prominent change is noted in the lesions in the lower T-spine, some L-spines, L5-sacrum junction, compatible with degenerative change
        1. Increased activity in the maxilla and mandible. Dental problem may show this picture.
        1. The previous some faint hot spots in bilateral rib cages are stationary, probably more benign in nature.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, left elbow, bilateral wrists, knees and ankles. Benign joint lesions are more likely.
    • 2022-03-01 Patho - urinary bladder TURBT
      • DIAGNOSIS:
        • A: Urinary bladder, TURBT — Non-invasive papillary urothelial carcinoma, high grade — Muscularis proria present without tumor
        • B: Urinary bladder, deep cut, TURBT — Negative for malignancy — Muscularis proria present without tumor
      • MICROSCOPIC DESCRIPTION:
        • A: Section shows high grade papillary urothelial carcinoma with focal cauterized artifact. No subepithelial invasion is found. Focal muscular layer is seen without tumor.
        • B: Section shows smooth muscular tissue without tumor.
    • 2022-02-28 CT - abdomen, pelvis
      • Wall thickening of urinary bladder.
    • 2021-09-24 Patho - urinary bladder TURBT
      • PATHOLOGIC DIAGNOSIS
          1. Urianry bladder, “tumor”, left, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
          1. Urinary bladder, “deep cut”, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
      • MICROSCOPIC EXAMINATION
          1. Histologic type: Papillary urothelial carcinoma, non-invasive
          1. Histologic grade: High-grade
          1. Tumor configuration: Papillary
          1. Muscularis propria: Present
          1. Lymphovascular invasion: Not identified
          1. Microscopic tumor extension: Tumor is non-invasive
          1. Specimen labeled “deep cut”: Non-invasive papillary urothelial carcinoma, high-grade
          1. Additional pathologic findings: Necrotizing inflammation
    • 2021-07-09 Patho - urinary bladder TURBT
      • DIAGNOSIS:
          1. Urinary bladder, “tumor”, TUR-BT — Infiltrating urothelial carcinoma, high-grade — Muscularis propria present and no tumor involvement
          1. Urinary bladder, “deep cut”, TUR-BT — Negative for malignancy — Muscularis propria present and no tumor involvement
    • 2021-04-09 urinary bladder biopsy
      • PATHOLOGIC DIAGNOSIS
          1. Urianry bladder, “tumor”, lateral wall, left, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
          1. Urinary bladder, “tumor base”, TURBT — Free
      • MICROSCOPIC EXAMINATION
          1. Histologic type: Papillary urothelial carcinoma, non-invasive
          1. Histologic grade: High-grade
          1. Tumor configuration: Papillary
          1. Muscularis propria: Present
          1. Lymphovascular invasion: Not identified
          1. Microscopic tumor extension: Tumor is non- invasive
          1. Specimen labeled “tumor base”: Free of tumor
          1. Additional Pathologic findings: Necrotizing granulomatous inflammation
    • 2021-02-01 MRI - lower abdomen
        1. S/P left nephrectomy.
        1. Focal mucosal thiekening at urinary bladder base, suggest cystoscope correlation.
    • 2021-01-12 Patho - urinary bladder TURBT
      • PATHOLOGIC DIAGNOSIS
          1. Urianry bladder, “bladder tumor”, TURBT — Non-invasive papillary urothelial carcinoma, high-grade
          1. Urinary bladder, “tumor base”, TURBT — Free
      • MICROSCOPIC EXAMINATION
          1. Histologic type: Papillary urothelial carcinoma, non-invasive
          1. Histologic grade: High-grade
          1. Tumor configuration: Papillary and flat
          1. Muscularis propria: Present
          1. Lymphovascular invasion: Not identified
          1. Microscopic tumor extension: Tumor is non-invasive
          1. Specimen labeled “tumor base”: Free of tumor
    • 2020-11-06 Patho - urinary bladder TURBT
      • DIAGNOSIS:
        • A. Urinary bladder, bladder tumor, TURBT — Urothelial carcinoma (low grade) invading submucosa. Muscularis propria present and not invaded.
          • IHC stain: GATA-3 (+), SMA (highlights +, muscle layer).
        • B. Urinary bladder, tumor base, TUR-BT — Free. Muscularis prorpia present and not invaded.
      • MICROSCOPIC DESCRIPTION:
        • A. Section shows multiple pieces of low grade invasive carcinoma, invading submucosa. Muscularis propria present and not invaded.
          • IHC stain: GATA-3 (+), SMA (highlights +, muscle layer).
        • B. Section show musculkaris propria and free of malignancy.
    • 2020-08-28 MRI - kidney, adrenals
        1. S/P Lt nephrectomy. There is no evidence of tumor recurrence.
        1. There is mild wall thickening in left lateral aspect of the urinary bladder. Please correlate with cystoscopy.
    • 2020-08-18 Tc-99m MDP whole body bone scan with SPECT
        1. In comparison with the previous study on 2019/10/22, the lesions in the middle and lower C-spines, lower T-spine, some L-spines and L5-sacrum junction are either stationary or a little less evident. Degenerative change may show this picture.
        1. Increased activity in the maxilla and mandible. Dental problem may show this picture.
        1. The previous some faint hot spots in bilateral rib cages are a little less evident, probably more benign in nature.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, left elbow, bilateral wrists, knees and ankles. Benign joint lesions are more likely.
    • 2020-08-11 Patho - urinary bladder TURBT
      • PATHOLOGIC DIAGNOSIS
          1. Bladder tumor, posterior wall, TURBT — Invasive papillary urothelial carcinoma, high grade
          • Muscularis propria, ditto — Absent
          1. Tumor base — Free from tumor
          1. Previous scar at left U/O — Chronic cystitis, compatible with scar
          • Muscularis propria, ditto — Present
          1. Previous TURBT scar at 5 o’clock bladder neck — Ulcer with fibrosis
          • Muscularis propria, ditto — Absent
      • MICROSCOPIC EXAMINATION
          1. Bladder tumor at posterior wall: invasive papillary urothelial carcinoma, high grade characterized by the pleomorphic tumor cells arranged in papillary or nest growth pattern with subepithelial invasion. Immunohistochemistry shows GATA-3(+), Uroplakin-II(+, scatter) and CK20(-) for tumor cells. Besides, Muscularis propria is absent in the limited specimen.
          1. Tumor base: muscularis propria only and free from tumor.
          1. Previous scar at left U/O: chronic cystitis, compatible with scar. Besides, muscularis propria is present and free from tumor.
          1. Previous TURBT scar at 5 o’clock bladder neck: ulcer with stromal fibrosis. Muscularis propria is absent.
    • 2020-05-29 Patho - urinary bladder TURBT
      • DIAGNOSIS:
        • A. Urinary bladder, “1. bladder tumornear UO”, TURBT — Urothelial carcinoma (high grade), invading muscularis propria.
          • IHC stains: CK20 (diffuse +, whole layer), CD44 (-), SMA highlights muscularis propria with tumor invasion.
        • B. Urinary bladder, “2. bladder tumor at the prostatic urethra”, TURBT — Urothelial carcinoma (high grade), invading submucosa.
        • C. Urinary bladder, “3. deep cut of bladder tumor near UO”, TURBT — free, muscularis propria present and not invaded.
      • MICROSCOPIC DESCRIPTION:
        • A. Section shows multiple pieces of urothelial carcinoma composed of papillary structures lined by urothelial cells with enlarged, hyperchromatic nuclei, high N/C ratio and mitoses up to 3/HPF. Tumor invades muscularis propria. IHC stains: CK20 (diffuse +, whole layer), CD44 (-), SMA highlights muscularis propria with tumor invasion.
        • B. Section shows urothelial carcinoma (high grade), invading submucosa.
        • C. Section shows soft tissue with no tumor, muscularis propria present and not invaded.
    • 2020-04-13 Patho - kidney partial/total resection
      • PATHOLOGIC DIAGNOSIS
          1. Renal calyx, left, nephroureterectomy — Invasive papillary urothelial carcinoma, high-grade
          1. Renal pelvis, ditto — Free of tumor
          1. Renal parenchyma, ditto — Tumor invasion
          1. Renal hilum, ditto — Tumor emboli present
          1. Perinephric fat, ditto — Free of tumor invasion
          1. Gerota’s fascia, ditto — Free of tumor invasion
          1. Ureter, ditto — Non-invasive papillary urothelial carcinoma, high-grade
          1. Ureter cutting end& bladder cuff, ditto — Free of tumor
          1. Lymph node, dissection — Free of tumor including hilum (0/1) and peri-renal fat (fat only)
          1. AJCC Pathologic Staging — ypT3N0 (if cM0), stage III
    • 2020-02-24 MRI - kidney, adrenals
      • Left renal caliceal tumor, regression as compare with CT study on 2019-07-17.
    • 2019-10-24 Effective renal plasma flow (ERPF)
        1. The ERPF of the right kidney was 161.3 ml/min, and the ERPF of the left kidney was 80.8 ml/min (normal reference range of ERPF: > 150 ml/min in each kidney for adults).
        1. After furosemide administration, the radiotracer washout was smooth from bilateral kidneys, indicating no definite evidence of obstructive hydronephrosis. Please correlate with other clinical findings for further evaluation.
    • 2019-10-22 Whole body bone scan with SPECT
        1. Increased activity in the middle and lower C-spines, lower T-spine and L5-sacrum junction. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
        1. Increased activity in the maxilla and mandible. Dental problem may show this picture.
        1. Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows wrists, knees and ankles. Benign joint lesion is more likely.
    • 2019-10-04 Surgical pathology Level IV
      • DIAGNOSIS:
        • Kidney, left upper calyceal, biopsy —Non-invasive papillary urothelial carcinoma, high grade
      • MICROSCOPIC DESCRIPTION:
        • Section shows high grade papillary urothelial carcinoma. No subepithelial invasion is found. Please correlate with the clinical presentation and further examination is suggested.
  • consultation
    • 2022-07-15 Urology
      • A
        • S
          • This 68-year-old male had history of
              1. Bladder urothelial carcinoma,cT2N0M0 s/p TUR-BT for 8 times on 2020/05/29, 2020/08/10, 2020/11/06, 2020/11/06, 2021/01/12, 2021/04/09, 2021/07/09, 2021/09/24, 2022-03-01 s/p intravesical chemotherapy, s/p gemcitabine + carboplatin, s/p radiotherapy.
              1. Left renal pelvis urothelial carcinoma, ypT3N0cM0, stage III s/p neoadjuvant chemotherapy and laparoscopic nephroureterectomy with bladder cuff resection on 2020/4/10; Recurrent tumor found in right side by cystoscopy on 2022/02/16
              1. Chronic kidney disease.   
              1. Bladder cancer s/p robotic-assisted radical cystectomy and right PCND on 2022/04/18, 2022/06/21; Urothelial cell carinoma, pT4aN0M0 stage IIIA.
          • He was just diacharged from our hospital due to dislodgement of right PCN. Revision of right PCN was done on 7/13. Severe right flank pain was noted for one day. The pain was associated with respiration.
          • He denied fever/chillness, nor turbid urine from PCN bag.
        • O
          • PE: right flank tenderness, no rebound pain, no muscle guarding
          • Lab data:
            • WBC 14.54k without bandemia (N/L: 85.6/6.2%), Hb 8.8 g/dL; Plt 303 k/uL
            • creatinine: 2.53 (improved) CRP 12.4 mg/dL
            • U/A clear; leuckocyte esterase 1+; NIT -; RBC 10-19/HPF;WBC 6-9/HPF; bac 1+/HPF
          • Abdominal CT: no urinoma, no fat stranding of right kidney, suspected new lesion at liver and a tumor above umbilicus
        • Imp:
          • UTI, metastatic UC
        • Suggestion:
          • antibiotics treatment with cephalexin and pain control with regular tramacet
          • OBS for one night and OPD follow up
    • 2022-04-15 Nephrology
      • Q
        • For hemodialysis evaluation
        • The 63 year-old male patient this admission impression of bladder cancer, he received of: 1. RARC + pelvic LN dissection; 2. Right PCN on 20220414. Post operation then transfer to SICU for care. RIght PCN dysfunction was found, PCN re-do was done, The CRE: 2.33->3.95. we need your help for this patient under hemodialysis evaluation, Thanks a lot.
      • A
        • Consult for HD evaluation
        • O
          • WBC:16.95, Band: 13.3, CRP::7.91
          • BUN/Cre: 32/1.86(4/12)->24/2.33(4/14)->34/3.95(4/15)
          • PH: 7.39, PCO2: 38, PO2:169, HCo3:23.0
          • Na: 143, K:3.9, Ca:1.89
          • U/O:273ml
        • Impression:
          • Acute kidney injury stage 2 related to obstructive uropathy
        • Suggestion
          • No emergent HD indication.
          • Follow up U/O and renal function, ABG, electrolyte
          • If persistant oliguria, refractory metabolic acidosis, hyperkalemia, fluid overload, we will arrange HD
    • 2022-04-15 Radiological Diagnosis
      • Q
        • for right PCN dusfunction ( Arrange antegrade pyelography )
        • The 69 year-old male patient this admission impression of bladder cancer, he received of: 1. RARC + pelvic LN dissection; 2. Right PCN on 20220414. Post operation then tranfer to SICU for care. However, rigth PCN dysfunction was found. bed side echo showed rigth hydronephrosis, we need your help for this patient under antegrade pyelography examination, Thank`s a lot.
      • A
        • According to the clinical condition and imaging findings, PCN is indicated.
  • surgical operation
    • 2022-04-14
        1. RARC + pelvic LN dissection
        1. Right PCN
    • 2022-03-01 TURBT
    • 2021-09-24 Trnasurethral resection of bladder tumor
    • 2021-07-09 TURBT
    • 2021-01-12 TURBT + flexible URS of right ureter
    • 2020-11-06 TURBT + Right URS and DBJ insertion
    • 2020-08-10 TURBT
    • 2020-05-29 TURBT
    • 2020-04-10 Laparoscopic transperitoneal nephroureterectomy + bladder cuff resection left
  • chemoimmunotherapy
    • 2022-08-09 - vinblastine 3mg/m2 2mg 10min + doxorubicin 30mg/m2 40mg 24hr + carboplatin AUC 4 200mg 2hr
      • due to high blood creatinine level, MVAC (methotrexate (hold) + vinblastine + doxorubicin + cisplatin (changed to carboplatin))
    • 2022-07-12 - pembrolizumab 100mg 30min
    • 2022-06-21 - pembrolizumab 100mg 30min
    • 2022-05-30 - pembrolizumab 100mg 30min
    • 2022-03-03 - mitomycin-C 30mg/m2 1hr intravesical
    • 2021-11-10 - cisplatin 30mg/m2 1hr intravesical
    • 2021-11-03 - doxorubicin 30mg/m2 1hr intravesical
    • 2021-10-20 - mitomycin-C 30mg/m2 1hr intravesical
    • 2021-10-13 - cisplatin 30mg/m2 1hr intravesical
    • 2021-10-02 - doxorubicin 30mg/m2 1hr intravesical
    • 2021-09-24 - mitomycin-C 30mg/m2 1hr intravesical
    • 2021-08-25 - mitomycin-C 30mg/m2 1hr intravesical
    • 2021-08-18 - doxorubicin 30mg/m2 1hr intravesical
    • 2021-08-11 - cisplatin 30mg/m2 1hr intravesical
    • 2021-08-04 - mitomycin-C 30mg/m2 1hr intravesical
    • 2021-07-28 - doxorubicin 30mg/m2 1hr intravesical
    • 2021-07-21 - cisplatin 30mg/m2 1hr intravesical
    • 2021-07-09 - mitomycin-C 30mg/m2 1hr intravesical
    • 2021-06-02 - gemcitabine 1000mg 1hr intravesical
    • 2021-05-26 - gemcitabine 1000mg 1hr intravesical
    • 2021-05-15 - gemcitabine 1000mg 1hr intravesical
    • 2021-05-03 - gemcitabine 1000mg 1hr intravesical
    • 2021-04-24 - gemcitabine 2000mg 1hr intravesical
    • 2021-04-17 - gemcitabine 1000mg 1hr intravesical
    • 2021-04-09 - doxorubicin 30mg/m2 1hr intravesical
    • 2021-03-10 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2021-02-24 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2021-02-03 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2021-01-27 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2021-01-20 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2021-01-13 - cisplatin 30mg/m2 1hr intravesical
    • 2020-12-23 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2020-12-16 - cisplatin 30mg/m2 1hr intravesical
    • 2020-12-09 - cisplatin 30mg/m2 1hr intravesical
    • 2020-12-02 - cisplatin 30mg/m2 1hr intravesical
    • 2020-11-25 - cisplatin 30mg/m2 1hr intravesical
    • 2020-11-17 - Bacillus Calmette-Guerin live attenuated vaccine, intravesical
    • 2020-11-06 - cisplatin 30mg/m2 1hr intravesical
    • 2020-10-14 - cisplatin 30mg/m2 1hr intravesical
    • 2020-10-07 - cisplatin 30mg/m2 1hr intravesical
    • 2020-09-30 - cisplatin 30mg/m2 1hr intravesical
    • 2020-09-23 - cisplatin 30mg/m2 1hr intravesical
    • 2020-09-16 - doxorubicin 30mg/m2 1hr intravesical
    • 2020-09-08 - doxorubicin 30mg/m2 1hr intravesical
    • 2020-08-21 - gemcitabine 1000mg/m2 30min + carboplatin 280mg 4hr
    • 2020-08-11 - doxorubicin 30mg/m2 1hr intravesical
    • 2020-07-28 - gemcitabine 1000mg 1hr intravesical
    • 2020-07-11 - cisplatin 35mg/m2 3hr IVD
    • 2020-07-10 - gemcitabine 1000mg/m2 30min + cisplatin 35mg/m2 3hr
    • 2020-06-24 - gemcitabine 1000mg/m2 30min
    • 2020-06-16 - cisplatin 35mg/m2 3hr IVD
    • 2020-06-15 - gemcitabine 1000mg/m2 30min + cisplatin 35mg/m2 3hr
    • 2020-05-30 - doxorubicin 30mg/m2 1hr intravesical
    • 2020-04-09 - doxorubicin 30mg/m2 1hr intravesical
    • 2020-02-25 - gemcitabine 1000mg/m2 30min
    • 2020-02-18 - gemcitabine 1000mg/m2 30min
    • 2020-02-07 - gemcitabine 1000mg/m2 30min + cisplatin 70mg/m2 3hr
    • 2020-01-21 - gemcitabine 1000mg/m2 30min
    • 2020-01-14 - gemcitabine 1000mg/m2 30min
    • 2020-02-07 - gemcitabine 1000mg/m2 30min + cisplatin 70mg/m2 3hr

==========

2022-08-16

  • 2022-08-16 stool OB 4+ with tranexamic acid and pantoprazole administrated.
  • Naproxen might be held temporarily for NSAIDs cause an increased risk of serious gastrointestinal adverse events, including bleeding, ulcers, and perforations of the stomach and intestines.

2022-07-26

  • 2022-07-22 CFP 19.28 mg/dL, Ceftriaxone 200mg QD IVD has been administrated. 2022-07-23 urine culture showed after 48 hours < 1000 CFU/mL, body temperature touched 39.4 degree 2022-07-26 09:43.
  • CrCl is 25 mL/min, no dose adjustment is needed for the drugs in active prescription.
  • If recent extended spectrum beta-lactamase (ESBL) isolated, then meropenem or imipenem might be an option.

701393637

220816

  • past history
    • essential thromobocythemia under hydroxyurea & anagrelide for yrs & spleen infartion s/p lower molecular heparin since 2019-04, now no more LMWH & hydroxyurea & anagrelide Tx.
  • exam finding
    • 2022-08-15 ECG
      • Sinus tachycardia
      • Possible Left atrial enlargement
      • Nonspecific T wave abnormality
    • 2022-08-15 Transfer
      • transferred from Cardinal Tien Hospital (2022-08-15) due to sepsis & pneumonia, anemia R/O GI bleeding, thrombocytopenia and left pevic fracture S/O ORIF (Open reduction internal fixation) on 20220805 and antibiotic with Mepem/Fluco was given for sepsis blood culture (Yeast-like and Cryptococcus neoformans (ARD), peumonia (sputum culture: acinetobacter pittii) and fungemia.
    • 2022-08-14 CT - brain (at Cardinal Tien Hospital?)
      • no definite brain lesion.
    • 2022-08-11 CT - chest (at Cardinal Tien Hospital?)
      • mild bilateral pleural effusion
    • 2022-08-02 SONO - abdominal (at Cardinal Tien Hospital?)
      • splenomegaly (17.5 cm)
    • 2022-08 Culture (at Cardinal Tien Hospital)
      • blood culture Yeast-like and Cryptococcus neoformans (ARD),
      • peumonia (sputum culture: Acinetobacter pittii) and fungemia.
    • 2022-07-16 CXR
      • Increased infiltration in both lungs
      • Borderline enlarged cardiac sihoutte
    • 2022-07-16 ECG
      • Normal sinus rhythm
      • Minimal voltage criteria for LVH, may be normal variant
      • Nonspecific ST abnormality
      • Abnormal ECG
    • 2022-07-04 JAK2 single site mutation
      • target: JAK2 gene (p.V617F)
      • presence of mutation
    • 2022-06-20 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-06-20 SONO - abdomen
      • Right renal cyst.
    • 2022-03-21 CT - abdomen (at Cardinal Tien Hospital?)
      • splenomegaly.
    • 2022-03-11 Bone marrow (at ChangHua Christian Hospital)
      • JAK2 V617F.
      • hypocellular marrow with fibrosis.
      • Gr II myelofibrosis by reticulin & trichrome stain.
      • No BCR/ABL fusion gene.
      • No occult mets carcinoma cell found by cytokeratin immunostain.
  • consultation
    • 2022-08-15 Infectious Disease
      • Q
        • This 70-year-old woman, intermitent fever with chills S/P ABX treatment at Cardinal Tien Hospital. She was transferred to our hospital on 20220518.
        • The blood culture yielded yeast-like & sputum culture: Acinetobater pittii moderate. We need expertise to evaluate her condition thanks!

[assessment]

  • High serum osmolality 320 mOsm/Kg (2022-08-15), hydration with 0.45% NaCl 500mL BID.
  • Antimicrobial meropenem and fluconazole have been prescribed for Acinetobacter pittii and Cryptococcus neoformans respectively.
  • 2022-08-15 PLT 41 *10^3/uL. In the case of active bleeding, patients with thrombocytopenia should be transfused with platelets immediately to maintain platelet counts above 50,000/microL in most bleeding situations, including disseminated intravascular coagulation (DIC).
  • Drug dosages in active prescriptions have been adjusted in accordance with the patient’s current renal function (2022-08-15 creatinine 1.21 mg/dL).
  • There are no issues with the medication at present.

701007135

220815

{oropharyngeal cancer}

  • exam finding
    • 2022-08-12 CT - abdomen, pelvis
      • Few stones in the distal CBD, causing mild dilatation of the proximal CBD, CHD, and IHDs, are suspected. Please correlate with ERCP.
    • 2022-08-12 CXR
      • Tortous aorta with calcification is noted.
      • Emphysematous change over both lungs.
      • Osteopenia of the bony structure is noted.
    • 2022-07-13 Percutaneous gall bladder drainage
      • Distention of the gallbladder (by US images). S/P NG tube indwelling.
    • 2022-07-12 SONO - abdomen
      • Diagnosis
        • Gallbladder sludge
        • CBD dilatation
        • Cholecystopathy
        • Fatty liver, mild
        • Renal stone, right kidney
        • Small amount ascites
        • Bilateral pleural effusion
      • Suggestion
        • correlated with liver function test and clinical symptoms
    • 2022-07-08 ECG
      • Paroxysmal Atrial fibrillation
      • Low voltage QRS
      • Abnormal ECG
    • 2022-07-06 2D transthoracic echocardiography
      • Conclusion:
          1. Dilated RV with preserved RV systolic function; cor pulmonale?
          1. Preserved LV systolic function.
          1. Moderate TR.
          1. Sinus tachycardia.
    • 2022-07-05 CT - abdomen, pelvis
        1. Right renal stone.
        1. GB stones.
        1. Bilateral pleural effusion and ascites.
        1. Fatty liver.
    • 2022-07-04 CT - abdomen, pelvis
      • Dilated, swelling of the intestines with increased intestinal gas is found. Gastrogenteritis is favored.
      • Right renal staghorn stone.
      • Gallstone.
    • 2022-07-04 ECG
      • Undetermined rhythm
      • Marked ST abnormality, possible inferior subendocardial injury
      • Abnormal ECG
      • Left axis deviation
      • ST depression, consider subendocardial injury
    • 2019-12-30 CXR
      • Increased lung volumes.
      • Subsegmental ground glass opacity over Rt peripheral upper lung zone
      • Tortousity of thoracic aorta
    • 2019-03-29 CT - brain
      • Swelling of right frontal scalp.
  • consultation
    • 2022-07-12 Radiological Diagnosis
      • Q
        • The 73 years old male had history of 1). renal stone S/P ESWL for five times at MMH, 2). GU, DU, gastritis. 3). Oropharyngeal cancer diagnosis on 2022-05. 4). COVID-19 infection on 20220426. According to the statement of ER and family record. He was a heavy drinker/smoker before. Denied any systemic past history before diagnosis oropharyngeal cancer. This time he suffered from SOB on 20220704. Therefore his wife call 119 and sent to our ER for evalutation. At ER, he denied fever, N/V, constipation, diarrhea. COVID-19 infection positive on 20220426. Abdominal CT showed 1. Right renal stone. 2. Bilateral pleural effusion and ascites. 3. Fatty liver. Under impress of 1). Severe sepsis with septic shock 2). AKI 3). R/O GI bleeding. He was admitted to our MICU for further treatment.
        • After admission to our MICU, empirical antibiotic with cefepime was administered for sepsis control. Hypercapenia respiratroy failure episode intubation was on 20220705. Due to intermittent fever still episode, we change to Doripenem plus Targocid on 20220706. NPO and PPI plus adequate IVF for GI bleeing. Bloodtransfusion LRP and FFP for correct thrombocytopenia and abnormal coagulation. Inotropic with levohped plus albumin for shock. Unbalane electrolye was correct. Sedative medication with Fentanyl plus ativan. However KP pneumonia was diagnosis, keep doripenem use.Abdomen echo was performed, that report showed CBD dilatation.
        • For GB stone with CBD dilatation, so we need your help for PTGBD evaluation. Thanks!
      • A
        • According to the clinical condition and imaging findings, PTGBD is indicated.

700020247

220812

{Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020-01-13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine in 2020-04}

  • Past History
    • Medical history
        1. Hypertension
        1. Sick sinus syndrome (brady-tachy syndrome) post DDDR pacemaker in 2020/07
        1. Atrial fibrillation under amiodarone and Rivaroxaban
        1. Goiter
    • Surgical history
        1. Hemorrhoids, Grade III post hemorrhoidectomy on 2015/10/02
        1. Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020/01/13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine on 2020/04/01-2020/04/15 under partial response        
  • exam finding
    • 2022-08-12 MRI - upper abdomen
      • History and indication:
        • 20210712 CT: recurrent CCC 2.6 cm at S6, S/P surgery
        • 20191219 CT: CCC 2.6 cm at S5 with gallbladder invasion S/P op.
      • Findings
          1. S/P partial resection of S5 and S6 of the liver.
          • A hepatic cyst measuring 1 cm in S5 is noted.
          1. S/P cholecystectomy.
          1. There are several renal cysts on both kidney and the largest one measuring 1.6 cm in size at right middle pole.
          • Both kidney show small size that may be chronic renal disease. Please correlate with renal function.
          1. Compression fracture of T10-11.
          • Mild Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5 and L5-S1.
          1. There is no hyper-or hypodense lesion in the biliary system, pancreas, and spleen.
          • There is no ascites or lymphadenopathy.
          • The abdominal aorta and IVC are grossly unremarkable.
      • IMP:
        • S/P partial resection of S5 and S6 of the liver.
        • There is no evidence of tumor recurrence.
    • 2022-07-15 Tc-99m MDP whole body bone scan
        1. As compared with the previous study on 2021-04-19, the lesion in the lower T-spine is a little less evident.
        1. No prominent change is noted in other bone lesions, possibly more benign in nature.
    • 2022-06-30 ECG
      • Atrial-paced rhythm with prolonged AV conduction
      • Prolonged QT
    • 2022-06-28 SONO - abdomen
      • S/P cholecystectomy and partial resection of S5/6/8 liver.
      • Several renal cysts on both kidney and the largest one is measured about 3.4 cm in size at right middle pole.
    • 2022-04-13 MRI - upper abdomen
      • S/P partial resection of S5 and S6 of the liver.
      • There is no evidence of tumor recurrence.
    • 2022-03-24 CT - abdomen, pelvis
      • S/P liver operation. A poor enhancing tumor (1.4cm) in S6 of liver.
      • Renal and liver cysts (up to 3.7cm).
    • 2022-03-10 SONO - abdomen
      • S/P right liver operation. S/P cholecystectomy. Bil. renal cysts.
    • 2022-01-10 CT - abdomen, pelvis
      • S/P partial resection of S5 and S6 of the liver.
      • Please correlate with contrast enhanced dynamic CT or MRI.
    • 2021-08-06 Patho - liver partial resection
      • Pathologic diagnosis
        • Liver, S6, segmentectomy — Intrahepatic cholangiocarcinoma, recurrent
        • Pathologic Staging: rpT3Nx; Stage IIIA if cM0
      • Microscopic examination
        • Histologic Type: Intrahepatic cholangiocarcinoma, recurrent
        • Histologic Grade: Moderately differentiated (G2)
        • Tumor Growth Pattern: Mass-forming
        • Tumor Necrosis: Present
        • Tumor Extension: Tumor perforating the visceral peritoneum
        • Perineural Invasion: Present
        • Pathologic Staging: rpT3Nx; Stage IIIA if cM0
        • Margins
          • Parenchymal Margin: Free, 1.2 cm from closest margin
          • Hepatic Capsule: Involved by invasive carcinoma
        • Non-neoplastic liver: Mild portal inflammation, portal fibrosis, and mild fatty change (5%)
    • 2021-07-12 CT - liver, spleen, biliary duct, pancreas
      • S/P liver operation. A recurrent tumor (2.6cm) in S6 of liver.
    • 2021-07-02 SONO - abdomen
      • S/P cholecystectomy and partial resection of S5-8 liver.
      • There is an ill-defined hypoechoic lesion 2.33 x 1.67 cm in S6 of the liver.
      • Recurrent cholangiocarcinoma is highly suspected. Please correlate with contrast enhanced dynamic MRI.
      • Several renal cysts on both kidney and the largest one is measured about 3.34 cm in size at right middle pole.
    • 2021-04-29 MRI - liver, spleen
      • Imp: s/p S5 resection with post op. change.
      • No evidence of recurrent/residual tumor in the study.
    • 2021-04-19 Tc-99m MDP whole body bone scan
      • Increased radioactivity at the T10-11 spines is old and comes to less prominent compared with the previous study on 2020-04-29, indicating partial response to current therapy.
      • Suspected benign lesions in the maxilla, mandible, lower L-spine, bilateral shoulders, sternoclavicular junctions, wrists, hips and knees.
    • 2021-03-09 CT - abdomen, pelvis
      • Suspected band like heterogenoeous hyperemic change at S5/S8 of liver is found. In comparison with CT dated on 2020-11-27, the lesion is stationary.
    • 2020-11-27 CT - liver, spleen, biliary duct, pancreas
      • Biloma in S5/8 of the liver show decreasing in size.
      • Two ovoid-shaped soft tissue lesions 1.5 x 1 cm and 1.3 x 0.8 cm in LLL of lung at lung window setting are noted that may be focal atelectasis with granuloma?
      • The differential diagnosis include metastases.
      • Follow up chest CT is indicated.
    • 2020-07-01 CT - liver, spleen, biliary duct, pancreas
      • Biloma in S5/8 of the liver is highly suspected.
      • Follow up is indicated.
    • 2020-01-14 Patho - liver partial resection
      • Pathologic diagnosis
        • Liver, S5, segmentectomy — Cholangiocarcinoma, large duct type
        • Lymph nodes, LN 12 and LN 8+7, dissection — No lymph node found
        • Gallbladder, cholecystectomy — Involved by carcinoma
        • Pathologic Staging: pT4Nx; Stage IIIB at least
      • Microscopic examination
        • Histologica Type: Cholangiocarcinoma, large duct type
        • Histologic Grade: G2 ( Moderately differentiated)
        • Tumor Growth Pattern: Mass-forming
        • Tumor Extension: Tumor invades gallbladder
        • Gall bladder margin: Uninvolved by invasive carcinoma
        • Lymphovascular Invasion: Present
        • Perineural Invasion: Present
        • Regional Lymph Nodes: No lymph nodes found
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Non-neoplastic liver: Mild portal inflammation and portal fibrosis
    • 2019-12-27 Surgical pathology Level V
      • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
    • 2019-12-23 Abdominal Ultrasonography
      • Hepatic tumor, right lobe, favor malignancy, r/o abscess
  • consultation
    • 2020-01-15 Thoracic Medicine
      • Q
        • For left pleural effusion
        • The male patient this admission impression of HCC, he was received of S5 resection on 20200113, post operation then transfer to SICU for care. The CXR showed left pleural effusion, we need your help for this patient chest echo examination and chest tapping.
      • A
        • The chest sono on 2020-Jan-15 showed (1) consolidation over left lower lung field (2) minimal amount pleural effusion over right thorax. Thus, thoracocentesis was not perforemd.
    • 2020-01-09 General and Gastroenterological Surgery
      • Q
        • This 80 years old man has the histories of
            1. Lumbosacral spondylosis without myelopathy
            1. Neuralgia,neuritis,and radiculitis,unspecified
            1. Sick sinus syndrome (brady-tachy syndrome) post pacemaker on 2009/06/08
            1. Atrial fibrillation
            1. Hemorrhoids, Grade III post hemorrhoidectomy on 2015/10/02.
        • This time, he suffered from fever (BT up to 39C) for 2 days, chills, epigastric pain about two days. The abdominal CT with contrast was done which revealed A poor enhancing lesion (2.6cm) in S5 of liver. DDX: early phase abscess, hypovascular tumor; Suspected hemangiomas (3mm, 8mm) at right heaptic lobe; Renal cysts (up to 3.1cm) and tiny gallbladder stones (1-2mm). CXR showed borderline heart size enlargement. Abdominal sonography was done which revealed hepatic tumor, right lobe, favor malignancy, suspected abscess. The tumor markers (CA19-9 3096.87 IU/mL; CEA 14.43ng/mL), the liver biopsy was arranged on 2019/12/27 and pathology reported Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma. Chest CT showe T10-T11 spondylodiscitis and favor left lung infection with pleural effusion. no metastatic lung nodule. liver tumor, cholangiocarcinoma.
        • We need your expertise for surgical intervention of cholangiocarcinoma. Thanks.
      • A
        • This case with liver tumor with cholangiocarcinoma was impressed.
        • Suggest:
            1. consult CV for heart and pacemaker evaluation.
            1. arrange cardiopulmonary function
            1. we will arrange operation after data report
  • surgical operation
    • 2021-08-05
      • Surgery
        • S6 resection
        • IOE
      • Finding
        • severe intraabd adhesion due to last hepatectomy
        • 2 x 1.8 x 1.5 cm well define tumor at S6 with retroperitoenal invasion
    • 2020-01-13
      • Surgery
        • S5 segmentectomy
        • cholecystectomy
        • hepato-duodenal ligament LN dissection
        • intraoperative echo
        • laparoscope
      • Finding
        • 4.5 x 4.0 x 2.5 cm tumor at S5 with GB invasion
        • no obvious LN was noted at station 12 and 8
  • radiotherapy
    • 2020-04-01 ~ 2020-04-15 - 3000cGy/10 fractions (6 MV photon) to T8-12 rib, Rt 9th rib.
  • chemoimmunotherapy
    • 2022-08-10 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2022-07-12 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2022-06-13 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2022-05-16 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2022-04-26 - gemcitabine 1000mg/m2 1700mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr
    • 2022-04-11 - gemcitabine 900mg/m2 1500mg 30min + carpoplatin AUC 3 150mg 2hr + fluorouracil 1000mg/m2 3400mg 46hr

==========

2022-08-12

  • There has been a slow decline in tumor markers in the past six months, which might indicate that the treatment is having a positive impact.
    • CEA
      • 2022-08-12 5.525 ng/ml
      • 2022-08-12 5.962 ng/ml
      • 2022-06-21 8.350 ng/mL
      • 2022-04-12 6.903 ng/ml
      • 2022-03-09 10.570 ng/mL
    • CA199
      • 2022-08-12 209.425 U/ml
      • 2022-08-12 242.735 U/ml
      • 2022-06-21 235.360 U/mL
      • 2022-04-12 273.730 U/ml
      • 2022-03-09 300.520 U/mL
  • Blood creatinine level around 2 mg/dL since April 2022 => eGFR 35 mL/min/1.73m2, CrCl 25 mL/min. Adjustments have been made to the following items:
    • rivaroxaban for patients with atrial fibrillation, nonvalvular (to prevent stroke and systemic embolism), CrCl 15 to 50 mL/minute: 15 mg once daily with the evening meal (AHA/ACC/HRS January 2014; AHA/ACC/HRS January 2019).
    • nebivolol for patients CrCl <30 mL/minute: Initial: 2.5 mg once daily; if initial response is inadequate, may increase cautiously.
    • spironolactone for patients eGFR 30 to 50 mL/minute/1.73 m2: Initial: 12.5 mg once daily or every other day; may double the dose every 4 weeks if serum potassium remains <5 mEq/L and renal function is stable, up to a maximum target dose of 25 mg/day (ACCF/AHA Yancy 2013).

2022-07-13

  • BH 160 cm, BW 68.6 kgw (2022-07-12), creatinine level around 2 mg/dL since April 2022 => eGFR 32.1 ~ 39.0 mL/min/1.73m2, CrCl 22.9 ~ 28.0 mL/min.
    • As with creatinine, BUN displayed a similar trend.
  • Options for adjusting the dose of the current regimen for patients with kidney impairment
    • Carboplatin:
      • The manufacturer’s labeling recommends the following dosage adjustments for single-agent therapy
        • Baseline CrCl 41 to 59 mL/minute: Initiate at 250 mg/m2 and adjust subsequent doses based on bone marrow toxicity.
        • Baseline CrCl 16 to 40 mL/minute: Initiate at 200 mg/m2 and adjust subsequent doses based on bone marrow toxicity.
        • Baseline CrCl <=15 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling.
      • Aronoff 2007 (for dosing based on mg/m2)
        • GFR >50 mL/minute: No dosage adjustment is necessary.
        • GFR 10 to 50 mL/minute: Administer 50% of the usual dose.
        • GFR <10 mL/minute: Administer 25% of the usual dose.
    • Gemcitabine
      • Discontinue if severe renal toxicity or hemolytic uremic syndrome occur during gemcitabine treatment.
  • The current dose of carboplatin is 150mg, which should remain within the acceptable range.

2022-05-17

  • No abnormalities in TPR. Lab data on 2022-05-16 showed general normal readings except for elevated blood creatinine (1.66 mg/dL) and BUN (47 mg/dL).
  • No issue with active prescription.

700064846

220812

  • exam finding
    • 2022-07-01 CXR
      • tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
      • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
      • reticular opacities at RUL due to fibrotic change
    • 2022-06-08 CXR
      • Atherosclerotic change of aortic arch
      • Few linear and nodular infiltrations in both lung are noted. please correlate with clinical condition.
      • S/P metalic autosuture at right upper lung.
    • 2022-04-18 CT - abdomen, pelvis
      • Colon cancer s/p RAR without recurrent/residual tumor in the study.
      • s/p right upper lobe wedge resection.
      • Hepatic simple cysts..
    • 2021-11-08 KUB
      • Surgical stiches and clips over abdomen
      • Suspect left renal stone
    • 2021-10-25 Patho - lung total/lobe/segmental
      • Lung, right upper lobe, VATS RUL wedge resection — Interstitial fibrosis
      • Microscopically, sections show Interstitial fibrosis characterized by stromal fibrosis with intervening vessels and focal deposition of pigment-laden histiocytes. The lung elsewhere shows is not remarkable.
      • Immunohistochemical stain reveals CK(-)
    • 2021-10-22 Patho - colon segmental resection for tumor
      • indication: Adenocarcinoma of ascending colon, cT3N0M1a (lung mets, but RUL frozen show fribrosis) s/p L-right hemicolectomy
      • pathologic diagnosis
        • Large intestine, ascending colon, SILS Right-hemicolectomy — Adenocarcinoma, moderately differentiated
        • Resection margins: free
        • Lymph node, mesocolic, dissection — Negative for malignancy (0/16)
        • Lymph node, IMA / SMA, dissection — N/A.
        • Appendix: Negative for malignancy
        • Pathology stage: pT3N0 (if cM0); AJCC stage IIA
    • 2021-10-21 CXR
      • Ground glass opacity in right lung.
    • 2021-10-21 Frozen section - lung
      • Lung, RUL, frozen section— Fibrosis
    • 2021-09-28 Whole body PET scan
        1. A glucose hypermetabolic lesion in the middle portion of the ascending colon, compatible with primary colon malignancy. However, no prominent FDG uptake was noted in the soft tissue nodule in the upper lobe of right lung delineated in the chest CT scan. Please follow up chest CT scan for further evaluation.
        1. A glucose hypermetabolic lesion in the left upper abdomen just between the stomach and left lobe of the liver. A metastatic lymph node should be watched out.
        1. A small glucose hypermetabolic lesion in the vertebral body of T10 spine only in the delayed imaging. Please follow up other imaging modalities for further evaluation and to rule out the possibility of early bone metastasis.
        1. Glucose hypermetabolism in some right upper neck level II lymph nodes. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
        1. Mild glucose hypermetabolism in right pulmonary hilar region. Inflammation may show this picture.
    • 2021-09-22 CT
      • Findings:
          1. There is soft tissue nodule 6 mm in RUL of the lung that may be metastasis. The differential diagnosis include primary lung cancer or lung parenchyma lymph node.
          1. There is mild wall thickening at the posterior aspect of the middle ascending colon measuring 1 cm in wall thickness that may be adenocarcinoma. Please correlate with colonoscopy.
          1. Fatty liver, grade 4-5, is noted. There are few small poor enhancing lesions on both hepatic lobes that may be cysts? The largest one measuring 0.6 cm in S6. Please correlate with sonography.
          1. Two small calcified renal stones in left lower pole are noted. A renal cyst measuring 3 cm in left lower pole is noted.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3 N:N0 M:M1a; stage:IVA
    • 2021-09-13 Patho - colon biopsy
      • Colon, middle ascending?/cecum?, 110 cm from anal verge, biopsy (A) — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
    • 2021-09-13 Colonoscopy
      • Diagnosis
          1. One ulcerative mass was noted in the middle ascending colon s/p biopsy
          1. Two polyps was noted in the ascending colon and sigmoid s/p polypectomy and clipped
      • Suggestion
        • F/U pathology report
    • 2021-09-13 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis
        • Gastric ulcer, antrum, PW
        • Gastric erosion, antrum, AW
        • Duodenal erosion, bulb, LC
        • Post self-paid CLO test
      • Suggestion
        • PPI use
        • Persue CLO test result
  • consultation
    • 2022-01-22 Dermatology
      • Q
        • This 59-year-old man patient is a case of Adenocarcinoma of A-colon, cT3N0M1a (0.6cm RLL nodule, suspected metastasis and liver nodules), stage IVa. He was admitted for chemotherapy with FOLFOX (C2D15).
        • This time, for right back of thigh mole and right foot thumb onychomycosis. Now, for evaluate right back of thigh mole and right foot thumb onychomycosis therapy. Thank you.
      • A
        • S: This patient suffered from dyskeratotic nails on bil sole for yrs
        • Imp: Tinea unguim
        • Suggestion:
          • Excelderm soln (sulconazole) *4 BT/Bid
  • chemoimmunotherapy
    • 2022-08-11 - oxalipaltin 50mg/m2 100mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr (oxa 24hr <- 2hr)
    • 2022-07-21 - oxalipaltin 75mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-06-06 - oxalipaltin 75mg/m2 150mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-05-06 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-04-15 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-03-25 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-03-02 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-02-10 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-01-21 - oxalipaltin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 4800mg 46hr
    • 2022-01-07 - oxalipaltin 85mg/m2 165mg 2hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 400mg/m2 775mg 10min + fluorouracil 2400mg/m2 4660mg 46hr
    • 2021-12-17 - oxalipaltin 85mg/m2 165mg 2hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 400mg/m2 775mg 10min + fluorouracil 2400mg/m2 4660mg 46hr
    • 2021-11-26 - oxalipaltin 85mg/m2 165mg 2hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 400mg/m2 775mg 10min + fluorouracil 2400mg/m2 4660mg 46hr

[assessment]

  • The patient was found to have pulmonary fibrosis in Oct 2021 (pathology and frozen section).
  • Studies have found that oxaliplatin is associated with pulmonary toxicity, and some of those suggested that the drug should be withheld for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis are ruled out.

700928517

220812

  • exam finding
    • 2022-07-11 CT - abdomen, pelvis
      • Presacral soft tissue mass, in enlargement. Rectal cancer progression is favored.
      • One growing low density at S8 of liver is found. Liver mets is hightly suspected.
    • 2022-05-25 Patho - colon resection
      • intestine, large, proximal transverse colon, revision of T colon colostomy — compatible with prolapse of colon
    • 2022-05-17 ECG
      • Right bundle branch block
      • Left anterior fascicular block
      • Bifascicular block
    • 2022-05-17 2D transthoracic echocardiography
        1. Preserved LV and RV systolic function with normal wall motion
        1. Dilated AsAo, LA and LV, grade 1 LV diastolic dysfunction
        1. Moderate to severe AR
    • 2022-03-05 CT - abdomen, pelvis
      • indication: Recurrent rectal cancer with impending obstruction s/p T loop colostomy on 2021/12/08 and concurrent chemoradiotherapy
      • Soft tissue mass at presacral space, in enlargement.
      • Liver low density lesions. Simple cysts are favored.
    • 2021-12-07 ECG
      • Normal sinus rhythm
      • Right bundle branch block
      • Left anterior fascicular block
    • 2021-11-23 Patho - colon biopsy
      • Rectum tumor, 6-7 cm above anal verge, biopsy — Adenocarcinoma
      • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
    • 2021-11-22 Colonoscopy
      • Diagnosis
        • Probable rectal cancer with recurrence, 6-7cm above AV, s/p biopsy for multiple pieces
      • Suggestion
        • F/U pathology report
    • 2021-11-19 CT - abdomen, pelvis
        1. Local recurrent tumor in the rectal fossa is suspected.
        1. Hemangioma 0.8 x 0.5 cm in S8 of the liver is suspected. Please correlate with sonography or MRI.
        1. Adenoma 2.8 x 2 cm of left adrenal gland is suspected. Please correlate with clinical condition and MRI.
    • 2021-05 CT - abdomen (at Far Eastern Memorial Hospital)
      • liver and adrenal mets.
    • 2021-02 CT - abdomen (at Far Eastern Memorial Hospital)
      • decreased size of liver mets but mildly increased size of para-aortic LAP.
    • 2020-08 CT - abdomen (at Far Eastern Memorial Hospital)
      • recurrence over liver and para-aortic LAP.
    • 2020-01 CT (at Far Eastern Memorial Hospital)
      • local recurrence over distal rectum involved with seminal vesicle.
    • 2017
      • recurrence of liver was noted, and he received the surgical intervention with segmentectomy of liver S3 on 2017-06-09.
    • 2014 initial presentation
      • indicental finding of rectal mass, liver mets was noted. without LAR, pT4bN1bM0, Stage III, s/p 1 dose of adjuvant chemotherapy.
  • consultation
    • 2021-12-28 Colon and Rectal Surgery
      • Q
        • The 73 y/o man has rectal cancer, cT4bN1bM0, Stage III with many times of recurrence s/p LAR (ypT3N0) s/p chemotherapy. He was admitted for salvage CCRT. Fever noted and suspect anal fistula with pus formation, so we need your help for management. Thanks!
      • A
        • Tumor recurrence with fistula formation
        • minimal abscess now
        • Need keep fistula opening by AgNO3 and empiric antibiotics treatment
    • 2021-12-27 Urology
      • Q
        • The 73 y/o man has recurrent rectum cacner under CCRT now. Due to dysuria, so we need your help for management. Thanks!
      • A
        • S
          • Initial presentation: 2014, rectal cancer,cT4bN1bM0, Stage III with many times of recurrence s/p LAR (ypT3N0), many times of chemotherapy
          • He was admitted for salvage CCRT.
          • Chief complaint: weak stream, intermittency, abdominal straining, and nocturia (2-3/per night) in recent 1 months, no sense of incomplete voiding
        • O
          • U/A: clear
          • TPV from CT: about 50 ml
          • PE: suspected an anal fistula with pus formation
        • Suggestion:
          • check PSA
          • arange UFR/PVR on 12/29 morning
          • also consult CRS for management of anal fistula
          • precribe harnalidge QD
  • surgical operation
    • 2021-12-08 T loop colostomy (at Far Eastern Memorial Hospital)
    • 2020-06-19 LAR, ypT3N0
    • 2017-06-09 surgical intervention with segmentectomy of liver S3 (which hospital ?)
  • radiotherapy
    • 2021-12-20 ~ 2022-01-10 - 4000cGy/16 fractions (15 MV photon) to recurrent rectal tumor
    • 2020-03-11 ~ 2021-04-15 - 4500cGy/25 fx (at Far Eastern Memorial Hospital)
  • chemoimmunotherapy
    • 2022-08-11 - irinotecan 150mg/m2 240mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 3900mg 46hr
    • 2022-07-29 - irinotecan 150mg/m2 240mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 3900mg 46hr
    • 2022-07-19 - irinotecan 150mg/m2 250mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • 2022-03-01 - irinotecan 150mg/m2 250mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • 2022-02-07 - irinotecan 150mg/m2 250mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • 2022-01-12 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 500mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • 2021-12-30 - leucovorin 20mg/m2 30mg 10min D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 (CCRT)
    • 2021-12-22 - leucovorin 20mg/m2 30mg 10min D1-2 + fluorouracil 400mg/m2 650mg 10min D1-2 (CCRT)
    • 2021-03-04 ~ 2021-05-09 - cetuximab plus FOLFOX (Oxa 85 mg/m2, LV 300 mg/m2, no bolus 5-FU, 5-FU 2600 mg/m2) for 4 doses (at Far Eastern Memorial Hospital)
      • the patient refused the further course of chemtoherapy due to intoleralbe side effect of mucositis, diarrhea, constipation, nausea and vomiting, and folliculitis over head.
    • 2020-08-18 ~ 2020-10-27 - FOLFOX * 5 (at Far Eastern Memorial Hospital)
    • 2020-03-11 ~ 2020-04-15 - weekly HDFL* 6 (CCRT) (at Far Eastern Memorial Hospital)

[note]

[assessment]

  • The 5-FU bolus is skipped since the patient has been refused treatment at Far Eastern Memorial Hospital in first half of 2021 due to intolerance of side effects.
  • Vital signs and lab data during this hospitalization were generally normal.
  • There is no issue with active prescription.

701391524

220811

  • exam findings
    • 2022-07-26 ECG
      • Sinus rhythm with 1st degree A-V block
      • Low voltage QRS
      • Borderline ECG
    • 2022-07-21 ECG
      • Right superior axis deviation
      • Anterior infarct, age undetermined
      • Nonspecific T wave abnormality
    • 2022-07-21 Gynecologic ultrasonography
      • Suspected Mild Adenomyosis
    • 2022-07-21 Pure-tone Audiometry, PTA
      • Reliabilty Fair
      • R’t : 13 dB HL
      • L’t : 19 dB HL
      • Bil WNL.
    • 2022-07-07 ECG
      • Sinus rhythm with 1st degree A-V block
      • Borderline ECG
    • 2022-06-23 MRI - brain
      • No evidenec of intracranial lesion.
    • 2022-06-23 Miniprobe Endoscopic Ultrasound
      • Endoscopic findings
          1. Multiple patchy esophageal lesion were noted from 42cm to 20cm. Under ME-NBI, brownish lesion with IPCL B1-2. Under lugol chromoendoscopy, multiple lugol voiding lesions were noted. Pink color sign (+)
          1. One raised and nodular mucosa lesion was noted at 28cm. Under ME-NBI, IPCL B-3 with large AVA was noted. Mucosa break <5mm was noted at EC junction.
      • EUS findings
        • Using EUS-DP- 25R, EUS showed a hypoechoic mucosal lesion with blurred 3rd layer at the lesion site. At least 3 lymph nodes were noted.
      • Diagnosis
          1. Esophageal cancer, at least cT1bN2, middle esophagus
          1. Rule out dysplastic esophageal lesion, diffuse middle and lower esophagus
          1. Reflux esophagitis
    • 2022-06-22 CT - lung/mediastinum/pleura
      • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T0N0M0
    • 2022-06-20 Patho - tonsil and/or adenoid
      • Palatine tonsil, right, tonsillectomy
        • — Well differentiated squamous cell carcinoma
        • — Margin free of tumor
      • Microscopically, section shows well differentiated squamous cell carcinoma consisting of nests and sheets of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity. The margin is free of tumor and 1~2 mm of closest margin distance.
    • 2022-06-15 Whole body PET scan
        1. A glucose hypermetabolism lesion in the left palatine tonsil, compatible with the primary tonsil cancer.
        1. Another glucose hypermetabolism lesion in the right palatine tonsil, the nature is to be determined, suggesting biopsy for investigation.
        1. Glucose hypermetabolism lesions in bilateral level III cervical lymph nodes, cancer with regional lymph nodes mets should be considered.
        1. A glucose hypermetabolism lesion in the left lower pelvis, the nature is to be determined also (urine, Gyn problems, or other nature ?), suggesting further investigation.
        1. Increased FDG uptake in bilateral kidneys and colon, probably physiological uptake of FDG.
        1. Left palatine tonsil cancer, cTxN2cM0, stage IVA at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2022-06-15 Patho - esophageal biopsy
      • Diagnosis
        • Esophagus, 28 cm below incisor, biopsy — well differentiated squamous cell carcinoma
      • Microscopically, section shows well differentiated squamous cell carcinoma consisting of sheets of squamous tumor cells with areas of dyskeratosis and focal stromal invasion. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • 2022-06-15 Patho - esophageal biopsy
      • Diagnosis
          1. Esophaus, 33 cm below incisor, biopsy— severe dysplasia, at least
          1. Esophaus, 40 cm below incisor, biopsy— mild dysplasia
      • Microscopically, section A shows severe dysplasia with squmoaus cells hyperplasia, nuclear hyperchromais and pleomorphism. There is no stromal component for evaluation of invasion. Section B shows mild dysplasia of squamous cells.
    • 2022-06-14 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A
        • Esophageal hyperemic patch, 33cm below the incisor (specimen A) and 40cm below the incisor (specimen B), s/p biopsy
        • Esophageal mucosa lesion, 28 below the insicor, s/p biopsy (C)
        • Superficial gastritis, s/p CLO test
        • Gastric erosions, prepyloric antrum
        • Duodenitits
        • Suspicious pseudodiverticulum, bulb
      • Suggestion
        • Pursue CLO test and biopsy result
    • 2022-06-13 MRI - larynx
      • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T2N2cM0, stage IVA
    • 2022-06-13 ECG
      • Normal sinus rhythm
      • Biatrial enlargement
      • Right superior axis deviation
      • Right ventricular hypertrophy
    • 2022-06-02 Patho - tonsil biopsy
      • Labeled as “left oropharynx”, biopsy — squamous cell carcinoma, well differentiated.
      • IHC stains: p16 (-), p40 (+), CK5/6 (+).
    • 2022-06-02 Nasopharyngoscopy
      • Findings
        • Oral cavity and oropharynx: an ulceration at L tonsillar fossa(esp L palatopharyngeal arch), a granular bulging at left velum posterior part visible from nasopharynx
        • Nasopharynx: fair via mirror/scope
      • Diagnosis
        • left oropharyngeal lesion

==========

2022-08-11

  • Renal function: female, age 45, weight 65, creatinine 4.43 => CrCl 16 mL/min, eGFR 12 mL/min/1.73m2.
  • Levocetirizine elimination route: 168 hours post dose an average of 85.4% of a radiolabeled dose was recovered with an average of 80.8% in the urine and 9.5% in the feces. Levocetirizine for CrCl 10 to 30 mL/minute: 2.5 mg twice weekly (every 3 or 4 days).

2022-08-02

  • Recent creatinine level trend
    • 2022-07-30 6.03 mg/dL
    • 2022-07-29 5.80 mg/dL
    • 2022-07-27 4.69 mg/dL
    • 2022-07-25 2.31 mg/dL
    • 2022-07-21 0.79 mg/dL
  • Suspected AKI. Calculated CrCl based on Cockcroft-Gault formula is 13 mL/min, and eGFR by MDRD equation is approximate 8 mL/min/1.73m2.
  • For patients with kidney impairment:
    • Cefepime for CrCl 11 to 29 mL/min: max 1 g every 12 hourse or 2 g every 24 hours, no dose adjustment is needed.
    • Cimetidine for GFR <10 mL/min: 300 mg every 8 to 12 hours, no dose adjustment is needed.
    • Levocetirizine for CrCl 10 to 30 mL/minute: 2.5 mg twice weekly (every 3 or 4 days). The current dose form is 5mg per tablet, which is difficult to administer to meet the aforementioned. Allegra (fexofenadine 60mg/tab, available in stock) is an alternative that is recommended at a dose of #1 QD.

2022-07-27

  • Nasogastric tubes can be used to administer all oral medications in active prescriptions.
  • Ascorbic acid included in Lyo-povigent inj may improve the absorption of iron supplement (ferrous sodium citrate) from the stomach.

700353371

220810

  • past history
    • Diabetes mellitus for years under regular OHA control.
    • Hypertension for years under regular medication control.  
  • exam finding
    • 2022-08-05 Pure Tone Audiometry, PTA
      • Reliabilty Fair to Poor
      • PTA
      • R’t : 30 dB HL, normal to moderately severe SNHL
      • L’t : 34 dB HL, normal to severe mixed type HL.
    • 2022-07-26 CT - neck
      • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage): T:T2/T4, N:N2C, M:M0, stage IVA
    • 2022-07-20 Patho - larynx biopsy
      • DIAGNOSIS:
        • A: Hypopharynx, pyriform sinus, right, biopsy — Squamous cell carcinoma, moderately differentiated
        • B: Oropharynx, soft palate, right, biopsy — Chronic inflammation
      • MICROSCOPIC DESCRIPTION:
        • A: Section shows squamous mucosa with invasive squamous cell carccinoma. The immunohistochemical stains reveal CK(+) and p63(+).
        • B: Section shows squamous mucosa with chronic inflammation. No invasive tumor is seen.
    • 2022-07-19 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-07-14 Nasopharyngoscopy
      • smooth NPx, oropharynx, right pyriform sinus yellowish granular tumor, saliva pooling
  • consultation
    • 2022-07-19 Oral and Maxillofacial Surgery
      • Q
        • This 71-year-old man has history of diabetes mellitus and hypertension over 2 years under regular medication control. The patient suffered from left mouth floor cyst suspect ranula noted in 2012-02, right buccal erythroplakia with mild uneven surface s/p biopsy on 20120325, the patho revealed minimal chronic inflammation.
        • This time, throat foreign body sensation, dysphagia, easy chocking and trismus 1.5 fingers were complained for 2 weeks. He came to our ENT OPD for help. Physical examination revealed trimus (1.5FB), soft palate fibrosis, right buccal and R soft palate erythroplakia with mild uneven surface, right pyriform sinus yellowish granular tumor, saliva pooling.
        • Under the impression of right oropharyngeal tumor and right oral lesion suspect malignancy, He was admission for lesion biopsy. We request your consultatio for dental evaluation.
      • A
        • This is a 71 y/o male who suffered from right oropharyngeal tumor and right oral lesion suspect malignancy.
        • O:
            1. Poor oral hygiene was noted
            1. Severe bone loss of tooth 27 47 and 44-33 was noted. No mobility was noted
        • A:
          • Sever periodontits of toooth 27 47 and 44-33.
        • P:
            1. Take panoramic film for tooth evaluation
            1. Suggest conservative treatment or tooth 27 47 extraction before further treatment
            1. OHI and teach him how to do home care
  • surgical operation
    • 2022-07-20
      • Surgery
        • Laryngomicrosurgery        
        • Biopsy of oral mucosa
        • Rigid esophagoscopy
      • Finding
          1. Right pyriform sinus medial wall and anterior wall granular tumor
          1. Rigid esophagoscopy: 18cm from incisor, free of tumor
          1. Erythroplakia at right soft palate and right retromolar trigone
          1. Removal of teeth #27,47
  • chemoimmunotherapy
    • 2022-08-08 - docetaxel 30mg/m2 55mg 1hr + cisplatin 40mg/m2 75mg 2hr + fluorouracil 2000mg/m2 3850mg 48hr

[assessment]

  • TPR were relatively stable during this hospitalization.
  • In general, blood pressure is well controlled, except for a transient episode of hypotension on 2022-08-09.
  • Blood sugar levels fluctuated between 100 mg/dL and 200 mg/dL, no urgent intervention is required.
  • Metoclopramide and chlorpromazine are independently associated with development of extrapyramidal symptoms (EPS) and neuroleptic malignant syndrome (NMS). The former is administered as TIDAC and the latter is administered as PRNHS, these two are not administered simultaneously, thus minimizing the risk.
  • There is no issue with the active prescription.

700515879

220805

{Right upper lung adenocarcinoma, moderately differentiated with bone metastasis, stage IV}

  • diagnosis
      1. Malignant neoplasm of unspecified part of unspecified bronchus or lung
      1. Lung cancer with bone metastasis, stage IV
      1. Essential (primary) hypertension
      1. Pure hypercholesterolemia
      1. Chronic viral hepatitis B without delta-agent
  • exam finding
    • 2022-08-05 Pure Tone Audiometry, PTA
      • PTA
      • Reliability FAIR
      • Average RE 29 dB HL; LE 50 dB HL.
      • R’t normal to severe SNHL.
      • L’t mild to severe SNHL.
    • 2022-07-11 PD-L1 IHC S2022-10376
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percent of PD-L1 expression in tumor cell (TC): < 1%
    • 2022-07-08 PD-L1 22C3 S2022-10376
      • Tumor Proportion Score (TPS): < 1%
    • 2022-07-08 PD-L1 SP142 S2022-10376
      • Tumor cell (TC) staining assessment: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): 0%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC < 1%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 0%
      • Note:
          1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
          1. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-07-08 EGFR mutation testing S2022-10376
      • No mutation was detected at exons 18 (G719X), 19 (Deletions), 20 (T790M, S768I, Insertions), 21 (L858R, L861Q) of EGFR gene in this specimen.
    • 2022-07-08 ROS1 Fluorescent-in-situ hybridization S2022-10376
      • Rearrangement of ROS1 gene is NOT detected.
    • 2022-07-08 ALK IHC S2022-10376
      • Immunostaining using ALK antibody D5F3 revealed no staining of tumor cells.
    • 2022-06-29 Pathology - lung transbronchial biopsy
      • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
      • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
    • 2022-06-28 CT - lung/mediastinum/pleura
      • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T4N3M1c
    • 2022-06-21 CXR
      • Patchy opacity projecting at right upper lung zone was noted, which might be bronchogenic carcinoma. Please correlate with CT.
      • Spondylosis of the T-spine
    • 2022-09-16 CT - abdomen, pelvis
      • S/P colon operation. A small nodule (5mm) at LUQ suspected tumor seeding. Lung and bony metastases.
    • 2022-06-09 MRI - L-spine
      • Diffuse bony metastases involving T10-S4 vertebral column and bony pelvis as described. Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L4-5 (with left HIVD). Post-operation change at L4-5.
    • 2019-07-31 L-spine AP + Lat. (including sacrum)
        1. post-OP change from L4 to L5; and mild scoliosis of the L-spine.
        1. moderate to severe decreased disc spaces in the L2/3 and L3/4 discs; and mild decreased disc space in the L1/2 disc.
        1. mild anterior and posterior spur formation in the L-spine
    • 2019-07-05 Doppler Flowmetry (perivasculary)
        1. Mild atherosclerosis of bil. infrapopliteal arteries without significant stenosis
        1. All triphasic flow spectrum from bil. CFA, PFA, SFA and popliteal arteries downstream to bil. PTA, ATA and DPA.
    • 2019-06-28 MRI - L-spine
      • Lumbar spondylosis with spinal canal stenosis and neuroforaminal narrowing, most severe on left side at L4-5.

[assessment]

  • Molecular and/or biomarker analyses were performed on this lung adenocarcinoma patient in order to identify gene alterations. The purpose of this is to identify potentially effective targeted therapies, as well as to avoid therapies that are unlikely to provide clinical benefits. However, the performed test results showed that PD-L1 TC < 1% & IC < 1%, no EGFR mutation detected, no ROS1 rearrangement detected, no immunostained ALK. An initial treatment option might be a regimen based on carboplatin or cisplatin.
  • Underlying condition HTN is well controlled during this hospitalization.

700529765

220805

  • exam finding
    • 2022-08-04 KUB
      • Presence of ileus.
    • 2022-08-04 CXR
      • Presence of ileus.
      • Multiple nodules at bil. lungs.
    • 2022-08-03 KUB
      • There is fecal materials impaction in the course of colons.
      • Local ileus.
    • 2022-06-21 CXR
      • Enlarged heart shadow with tortuous aorta.
      • Multiple nodules and masses in bilateral lungs, consider metastases, enlarging.
      • Bilateral clear costophrenic angles.
    • 2022-06-21 Ribs Bilat
      • Multiple nodules and masses in both lungs, consider metastases, enlarging.
      • No definite displaced rib fracture. Clinical correlation is advised.
    • 2022-06-21 CT - brain
      • Brain atrophy. No ICH.
    • 2022-06-21 ECG
      • Sinus rhythm with premature atrial complexes
      • T wave abnormality, consider anterior ischemia
      • Prolonged QT
    • 2021-10-12 ECG
      • Normal sinus rhythm
      • T wave abnormality, consider anterior ischemia
    • 2021-10-12 CT - abdomen, pelvis
      • Hx of rectal ca without Tx. Only receiving chinese medicine
      • Diffsue wall thickening of the rectum up to 7.5cm in length and swelling of the sigmoid colon and descending colon is found. Rectal cancer with colitis at sigmoid colon is considered.
      • Lung mets.
    • 2021-10-12 CXR
      • Tortous aorta with calcification is noted.
      • Nodular lesion at right upper lobe and right lower lobe is found.
      • Osteopenia of the bony structure is noted.
    • 2020-08-04 CT - lung/mediastinum/pleura
      • RLL solid nodule (15-mm) (in favor an another primary lung cancer).
      • Lingula tiny nodule, nature to be determined.
    • 2020-08-04 Patho - colon biopsy
      • Large intestine, rectum, biopsy — Adenocarcinoma, moderately differentiated
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2020-08-04 SONO - abdomen
      • Hepatic cyst, multiple
      • GB stone, mutiple
      • Renal cyst, bilateral
    • 2020-08-03 Sigmoidoscopy
      • Diagnosis
        • Rectal cancer with partial obstruction, s/p Bx
        • Internal hemorrhoid
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2020-08-03 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis
      • Suggestion
        • PPI treatment
  • consultation
    • 2021-10-14 Family Medicine
      • Q
        • for combine hospice care
        • This 78 year-old female patient who has rectal cancer, Stage IV on 2020/08, then she refusioned the surgery treatment, chemotherapy, radiotherapy.
        • This time, she suffered from watery diarrhea many times for one month due to the use of folk herbal recipes, then the symptom of waterly diarrhea progression, and poor intake, abdomen pain noted, so she was brought our ER for help.
        • The patient still refusion chemotherapy, radiotherapy, but want to combine hospice care, so we need your help, thanks a lot!!
      • A
        • Indication: rectal cancer, Stage I
        • Patient refuses cancer treatment and has no specific complaint while I visited.
        • We will arrange share to follow up.
        • She can visit FM OPD for symptom control after discharge.
    • 2020-08-04 Colorectal Surgery
      • Q
        • This 78 y/o female patient denied any systemic history before. She suffered from abdominal fullness and difficult stool passage for 4 days. She visited HoPing Hospital for help where suspected colon cancer by abdomen CT exam. High level of CRP 29 was noted. The patient then transfered to our OPD for personal reason. Denied fever, cough, chest pain, tarry stool passage, oliguria, nor limbs edema. The physical examination showed pink conjuctiva and soft abdomen. CEA on 20200729 31.7 ng/mL. Going to obtain routine blood test and further management.
        • Sigmoid scope showed rectal cancer with partial obstruction, s/p Bx; internal hemorrhoid. We would like to need your visit for professional help. Thank you very much!
      • A
        • I’ve visited this case.
        • This 78 y/o fenmale patient suffered from abdominal distension and no stool passage for 4 days and then rectal cancer with obstruction was diagnosed.
        • Stool passage (+) now and no more abdominal distension.
        • I’ve explained the necessity of surgical treatment, the patient denied any discomfort and ask for discharge today.
        • The risk of re-obstruction was told.
        • Suggest OPD F/U

[assessment]

  • The patient refused to receive surgery, chemotherapy, radiotherapy.
  • Elevated CRP (2022-08-04 11.68 <- 2022-08-03 8.57), normal WBC (2022-08-04 7.13). Brosym (cefoperazone/sulbactam) is prescribed.
  • All the oral drugs in active prescription can be administered with nasogastric tube without issues.

700642355

220805

{ovarian cancer, pT3aN0cM0, FIGO stage IIIA2}

  • exam finding
    • 2022-06-08 SONO - abdomen
      • Hydronephrosis, right
    • 2022-04-07 Patho - uterus with or without SO non-neoplastic/prolapse
      • Ovarian/ Fallopian tube/ Peritoneum Cancer Checklist
      • Diagnosis:
        • F2022-00147:
          • Ovary, left, oophorectomy —- Mucinous carcinoma
          • Ovary, right, oophorectomy —- Mucinous carcinoma
          • Fallopian tube, left, salpingectomy —- Not found
          • Fallopian tube, right, salpingectomy —- Negative for malignancy
        • S2022-05776
          • Uterus, corpus, total hysterectomy —- Negative for malignancy —- Leiomyoma
          • Uterus, endometrium, total hysterectomy —- Negative for malignancy
          • Uterus, cervix, total hysterectomy —- Negative for malignancy
          • Omentum, omentectomy —- Extravasated mucin present
        • AJCC 8th edition: pStage IIIA2, pT3aN0 (if cM0); FIGO Stage IIIA2
      • Gross description:
        • Procedure: ATH + BSO + Cytoreduction surgery + infracolic omentectomy + LN dissection
        • Microscopic Description:
          • Histologic Type: Mucinous carcinoma with abundant extravasated mucin; The immunohistochemical stains reveal PAX8(-), WT-1(-), PR(-), and p53(wild type).
          • Histologic Grade: G2: Moderately differentiated
          • Implants (required for advanced stage serous/seromucinous borderline tumors only): Not sampled
          • Other Tissue/ Organ Involvement (select all that apply): bilateral adnexal soft tissue and omentum: extravasated acellular mucin present
          • Largest Extrapelvic Peritoneal Focus (required only if applicable): omentum: Microscopic
          • Peritoneal/Ascitic Fluid: N2022-01327: Negative for malignancy
          • Regional Lymph Nodes: left iliac: 0/3; left obturator: 0/5; right iliac: 0/0; right obturator: 0/6; left para-aortic: 0/1; right para-aortic: 0/0.
          • Additional Pathologic Findings: A leiomyoma is seen.
    • 2022-04-06 Frosen Resection
      • FsA: Ovary, left, oophorectomy — mucinous adenocarcinoma
      • FsB: Ovary, right, oophorectomy — mucinous adenocarcinoma
    • 2022-04-01 Patho - stomach biopsy
      • Stomach, antrum, biopsy — Chronic gastritis, H pylori NOT present
    • 2022-03-29 Mammography
      • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative. - annual screening.
    • 2022-03-28 CT - abdomen, pelvis
      • Right hydronephrosis and hydroureter.
      • A cystic lesion (11.4cm) at left adnexa with septation suspected mucinous tumor. A tumor (5.9cm) at uterus suspected myoma.
    • 2022-03-28 Gynecologic ultrasonography
      • pelvis mass: 116x111mm
    • 2017-07-03 MRI - nasopharynx
      • Findings
        • Multiple ovoid and round nodular lesions in Rt level III, IV, Vab (the largest lesion 21mmx20mm)
        • An heterogeneous enhancing mass, lobulated in contour (heterogeneous hyperintensity on T2WI. mixed hyper-and intermediate intensity on T1WI) in the lower neck and thoracic inlet, which is inseparable from adjacent thyroid gland.
      • Impression:
        • In favor of thyroid cancer with neck LNs metastasis.
  • consultation
    • 2022-03-28 Obstetrics and Gynecology
      • Impression and plan:
          1. Huge ovarian mass, left side 116x111 mm, suspect malignancy.
          1. Uterine myoma: 69x43 mm
          1. Survey tumor marker CEA, CA125, CA199, AFP, SCC, D-dimer
  • surigcal operation
    • 2022-04-06
      • Operation
          1. Enterolysis
          1. Excision of intraabdominal malignant tumor
      • Finding
        • s/p lower midline incision scar with severe adhesion of small bowel to abdominal wall and lower pelvic cavity.
        • Several mucinous nodules were removed
        • Washing cytology: ascites*1
    • 2022-04-06
      • Surgery
        • Right hydronephrosis and hydroureter.A cystic lesion (11.4cm) at left adnexa with septation suspected mucinous tumor.
        • Left ovarian tumor (11.4 cm), suspected malignancy.
        • Frozen: mucinous adenocarcinoma
        • Debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy + LN dissection)     - Finding
        • Supraumbilical midline vertical skin incision
        • Uterus: enlarged, 8cm, tense contact with bladder, peritoneum dut to tumor mass accupied .
        • Adnexa:
          • LOV: 11.4x10x8cm , rupture during the operation , smooth surface.
          • ROV: 2x2x2 cystic mass , capsule not intact.
          • Fallopian tube: bilateral grossly normal
        • CDS: invisible due to tumor mass occupied
        • Ascites: bloody , minimal
        • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(-)
        • Omentum: grossly normal
        • Optimal debulking surgery was achieved.
        • Residue tumor: almost no residual tumors, maximal diameter < 1 cm, over rectum and peritonealwall.
        • Estimated blood loss:1000 ml
        • Blood transfusion: 4U
        • Complication: NIL
  • chemoimmunotherapy
    • 2022-08-04 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-07-13 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-06-02 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-05-12 - paclitaxel 160mg/m2 210mg 3hr + carboplatin AUC 5 600mg 2hr

==========

2022-06-27

  • The body temperature was no higher than 37 degrees since the night of 2022-06-25 after administration of Tapimycin (piperacillin 4g, tazobactam 0.5g) IVD Q6H since 2022-06-24.

700653751

220805

{newly diagnosed with Endometrioid adenocarcinoma T1BN0M0 stage IB s/p Laparoscopic gynecologic oncology staging surgery}

[objective]

  • lab data
    • Uric Acid
      • 2022-06-29 8.6 mg/dL
      • 2022-03-22 9.7 mg/dL
      • 2022-02-14 8.2 mg/dL
      • 2021-09-28 10.2 mg/dL
      • 2021-04-21 9.8 mg/dL
    • Hepatitis
      • 2022-02-24
        • Anti-HBs 97.17 mIU/mL Reactive
        • Anti-HBc Nonreactive 0.53 S/CO
        • Anti-HCV Nonreactive 0.04 S/CO
        • HBsAg Nonreactive 0.29 S/CO
  • exam finding
    • 2022-04-28 2D transthoracic echocardiography
      • Dilated LA
      • LV apical and septal hypertrophy
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR and TR
      • No regional wall motion abnormalities
    • 2022-03-16 Pure tone audiometry, PTA
      • Reliability FAIR
      • Average R’t 31 dB HL // L’t 35 dB HL
      • Bil normal to moderately severe SNHL.
    • 2022-02-16 Patho - uterus (with or without SO) neoplastic
      • pathologic diagnosis
        • Uterus, endometrium, laparoscopic staging surgery — Endometrioid adenocarcinoma, grade 3
        • Uterus, myometrium, LSC staging surgery — Involved by adenocarcinoma (more than half thickness)
        • Uterus, cervix, LSC staging surgery — Negative for malignancy
        • Ovaries and fallopian tubes, bilateral, LSC staging surgery — Negative for malignancy
        • Lymph node, left iliac, dissection — Negative for malignancy (0/4)
        • Lymph node, left obturator, dissection — Negative for malignancy (0/6)
        • Lymph node, right iliac, dissection — Negative for malignancy (soft tissue only)
        • Lymph node, right obturator, dissection — Negative for malignancy (0/6)
        • AJCC 8th edition Pathology stage: pT1bN0(if cM0); FIGO IB; AJCC stage IB
      • IHC: p53(wild type), p16(-), ER: positive (moderate, 40%), PR: positive (moderate, 40%)
    • 2022-02-11 MRI - pelvis
      • Soft tissue tumor in the uterine cavity, suspected endometrial malignancy, cStage T1bN0M0.
      • Suspected right ovarian cyst.
    • 2022-02-10 Gynecologic ultrasonography
      • suspected endometrial hyperplasia
      • suspected rt ovarian cyst
  • past history
    • Hypertension since 2003.
    • Angina pectoris, years ago, and myocardia ischemia with patent coronary artery with myocardial bridge at middle LAD by cardiac catheterization in 2015. Now under Apixaban treatment.
    • Obstructive sleep apnea for years.
    • Diabetes mellitus, type II, under OHAs treatment.
    • Hyperlipidemia.
    • Chronic Af under medication treatment. 
  • surgical operation
    • 2022-02-16
      • Surgery
        • Laparoscopic gynecologic oncology staging surgery        
      • Finding
        • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
        • Bilateral adnexa: grossly normal
        • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
        • CDS: free
        • Adhesion between omentum and pelvic wall was noted
  • radiotherapy
    • 2022-03-17 ~ 2022-05-05 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
  • chemotherapy
    • 2022-08-04 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 270mg 2hr
    • 2022-07-08 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 270mg 2hr
    • 2022-06-17 - paclitaxel 175mg/m2 240mg 3hr + carboplatin AUC 5 270mg 2hr
    • 2022-05-24 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 300mg 2hr
    • 2022-04-19 - carboplatin AUC 4 300mg 2hr (due to cisplatin caused high creatinine level)
    • 2022-03-23 - cisplatin 50mg/m2 80mg 24hr (NCCN 20211104 Uterine Neoplasms p32 ENDO-D 1/4 - carboplatin + paclitaxel)

==========

2022-08-05

  • After a switch from cisplatin to carboplatin in April 2022, the blood creatinine level has returned to normal since late June 2022.
  • According to available records, the level of blood uric acid was above the normal range for more than 12 months.
    • 2022-06-29 8.6 mg/dL
    • 2022-03-22 9.7 mg/dL
    • 2022-02-14 8.2 mg/dL
    • 2021-09-28 10.2 mg/dL
    • 2021-04-21 9.8 mg/dL
  • For patients at a high risk of an adverse cardiovascular event or have a history of a previous cardiovascular adverse event, an initial trial of a uricosuric agent rather than febuxostat is recommended, benzbromarone 50mg/tab 1# PO QD might be considered.

2022-06-20

  • An increase in S-GPT/ALT has been noted (2022-06-14 114 U/L <- 2022-05-31 9 U/L). The same trend could be seen in S-GOT/AST (2022-06-14 25 U/L <- 10 U/L)
    • Paclitaxel has been associated with serum aminotransferase elevations in 7% to 26% of patients, but values greater than 5 times the upper limit of normal (ULN) in only 2% of those receiving the highest doses. ( https://www.ncbi.nlm.nih.gov/books/NBK548093/ )
    • Mild and transient elevations in serum aminotransferase levels are found in up to one-third of patients taking carboplatin. However, clinically apparent acute liver injury from carboplatin is extremely rare and the characteristics of such injury have not been well defined. ( https://www.ncbi.nlm.nih.gov/books/NBK548565/ )
  • The underlying condition Three-Hypers which are currently managed through oral medication and Metabolism OPD follow-up, however patient’s SBP was 91~191 and blood sugar was 123~490, both with high volatility. In terms of HbA1c, LDL, and Triglyceride, the last test results were dated in December 2021.

2022-05-24

  • This patient was diagnosed with endometrioid adenocarcinoma in early 2022, had staging surgery in February 2022, received CCRT between March and early May 2022, and begins to receive carboplatin/paclitaxel.
  • Most recent lab data reported on 2022-05-12 showed slightly decreased blood cell counts. BUN and Creatinine levels were improving (BUN 22 (2022-05-12) <- 47 (2022-04-28); Creatinine 1.28 (2022-05-12) <- 1.76 (2022-04-28)).
  • The patient also has “Three-Hypers” which are managed through oral medication (prescribed as self-carried items in active order currently) and Metabolism OPD follow-up, however, in terms of HbA1c, LDL, and Triglyceride, the last test results date back to December 2021 and might need to be updated.

2022-04-19

  • The patient has been recently diagnosed with endometrioid adenocarcinoma stage IB s/p laparoscopic gynecologic oncology staging surgery, and is receiving EBER since 2022-03-17 and cisplatin since 2022-03-23.
  • Lab data on 2022-04-19 and 2022-04-12 were grossly normal. Cardiac conditions are managed with corresponding drugs. TPR readings are normal. There is no information on blood sugar levels during this hospital stay yet.

700516604

220801

  • exam finding
    • 2022-07-30 CXR
      • Ground glass opacities in bil. lungs.
    • 2022-07-30 KUB
      • Stool retention in the bowel.
      • Degeneration and spondylosis of L-S spine.
    • 2022-07-21 CXR
      • lung markings: consolidation in the right lower lung field; focal increased density in the right middle lung field.
      • blurred right hemidiaphram
      • blunting bilateral costophrenic angles
    • 2022-07-14 Paracentesis
      • Ascites tapping: 3000mL orange ascites
    • 2022-07-08 Paracentesis
      • Ascites tapping: 3000mL bloody ascites
    • 2022-06-25 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
    • 2022-06-14 CT, CTA - chest
      • Finding
        • Filling defects of bilateral pulmonary arteries, lobar and segmental branches.
        • Dilatation of right ventricle and pulmonary trunk.
        • Small amount of pleural effusion.
        • Liver cirrhosis and ascites.
        • Increased para-aortic soft tissue density.
      • Impression
        • Pulmonary embolism, lobar and segmental branches
    • 2022-06-14 ECG
      • Normal sinus rhythm
      • Rightward axis
      • Low voltage QRS of precordial leads
      • T wave abnormality, consider inferolateral ischemia
      • Prolonged QT
      • Abnormal ECG
    • 2022-06-07 CT - abdomen, pelvis
      • Pancreatic head cancer s/p operation. Partial thrombosis of IVC.
      • General subcutaneous edema. Small amount ascites. Bil. pleural effusions.
      • Small patchy densities (0.5cm, 0.6cm) at LLL.
      • A poor enhancing nodule (2.3cm) at S6 of liver.
      • Some LNS at retroperitoneum with SMV encasement.
    • 2022-03-26 ECG
      • Sinus tachycardia
      • T wave abnormality, consider anterior ischemia
      • Abnormal ECG
    • 2022-03-10 CT - abdomen, pelvis
      • Pancreatic head cancer s/p operation.
      • Bil. pleural effusions. A small patchy density (1.0cm) at LLL suspected metastases.
      • A poor enhancing nodule (2.2cm) at S6 of liver suspected metastases.
      • Some LNS at retroperitoneum.
    • 2022-03-10 CXR
      • Increased lung markings on left lower lung with blurring of left medial diaphragm is noted. Please correlate with clinical condition.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
    • 2022-02-18 2D transthoracic echocardiography
        1. Dilated RA and RV
        1. Adequate LV systolic function with normal wall motion
        1. Mild to moderate TR and PR
        1. Thick IVS
    • 2022-02-14 SONO - vein
        1. Circumferential venous thrombosis at right ostial to proximal SFV with adequate recanalization, no venous thrombosis at right CFV, PFV, middle to distal SFV, popliteal vien, PTV and LSV.
        1. No venous thrombosis at left lower limb venous systems.
        1. Venous arterialization waveforms at bilateral CFVs, consider iliac compression syndrome.
        1. No significant venous refluxes at bilateral lower limbs venous systems.
        1. The ratios of MVO and SVC of bilateral legs were within normal limits.
    • 2022-02-11 2D transthoracic echocardiography
        1. Preserved LV and RV systolic function with normal wall motion
        1. Concentric LVH, grade 1 LV diastolic dysfunction
        1. Mild AR, MR, PR, mild to moderate TR
        1. Pulmonary hypertension
        1. Presence of thrombus in IVC
    • 2022-02-10 CT, CTA - chest
      • INFERIOR VENA CAVA thrombus with pulmonary embolism and bialteral upper lobe patch.
      • Pancreatic cancer in the abdominal cavity with stable condition.
      • Left lower lobe nodule. stable.
    • 2021-10-27 CT - abdomen, pelvis
        1. A newly-developed soft tissue nodule 4 mm in LLL of the lung is noted that may be metastasis? Follow up is indicated.
        1. Metastasis at the mesentery with superior mesenteric artery and vein encasement is suspected. please correlate with clinical condition and tumor marker.
        1. Metastasis or partial volume effect 0.9 cm in the pelvis is suspected?
    • 2021-06-19 CT - abdomen, pelvis
      • s/p subtotal gastrectomy.
      • s/p pancreatic head resection.
      • Some soft tissue mass around the SMA and SMV is found. In comparison with CT dated on 2021-01-22, the lesion is stationary.
    • 2021-01-22 CT - abdomen, pelvis
        1. Metastasis at the mesentery with superior mesenteric vein encasement is suspected. please correlate with clinical condition, tumor marker, and MRI.
        1. Metastasis or partial volume effect 0.9 cm in the pelvis is suspected?
    • 2020-04-15 Esophagogastroduodenoscopy, EGD
      • Gastric bleeding prob anasmtomotic site bleeding s/p APC
      • Reflux esophagitis LA Classification grade A
      • s/p whipple operation
      • incomplete study
    • 2020-04-09 Patho - pancreas total/subtotal resection
      • pathologic diagnosis
        • Pancreas, head, pancreatico-duodenectomy —- Adenocarcinoma, moderately differentiated;
          • AJCC 8th edition: ypStage IIB, ypT3N1(if cM0), s/p pre-op neoadjuvant treatment
        • Small intestine, duodenuma, pancreatico-duodenectomy —- Adenocarcinoma, by direct invasion
        • Portal vein, segmental resection —- Adenocarcinoma, by direct invasion
        • Common bile duct, pancreatico-duodenectomy —- Negative for malignancy
        • Stomach, pyloric, partial gastrectomy —- Negative for malignancy
        • Gallbladder, cholecystectomy —-chronic cholecystitis —- cholelithiasis
        • Lymph nodes
          • Lymph node, group 5, 6, 8, 9, 12, 13, 14, dissection —- Negative for malignancy (0/6)
          • Lymph node, cystic, dissection —- Negative for malignancy (0/1)
          • Lymph node, lesser curvature, dissection —- Negative for malignancy (0/3)
          • Lymph node, greater curvature, dissection —- Negative for malignancy (0/16)
          • Lymph node, peri-CBD, dissection —- Negative for malignancy (0/3)
          • Lymph node, peri-pancreas, dissection —- Adenocarcinoma, metastatic (1/6)
      • microscopic examination
          1. Histologic Type: Ductal adenocarcinoma
          1. Histologic Grade (ductal carcinoma only): G2: Moderately differentiated
          1. Margins
          • Margins: free, closest margin: 0.1 mm; Posterior retroperitoneal (radial) margin
          • Distal pancreatic margin: 1.2 cm
          • Common bile duct margin: 2.5 cm
          • Gastric margin: 9 cm
          • Small intestinal margin: 16 cm
          1. Lymphovascular invasion: Present
          1. Perineural Invasion: Present
          1. Pathologic Staging (pTNM)
          • Primary Tumor (pT): pT3: Tumor > 4 cm
          • Regional Lymph Nodes (pN): pN1: Metastasis in one to three regional lymph nodes
          • Specify: group 5, 6, 8, 9, 12, 13, 14: 0/6; cystic: 0/6; cystic: 0/1; lesser curvature: 0/3; greater curvature: 0/16; peri-CBD: 0/3; peri-pancreas: 1/6
          • Distant Metastasis (pM): if cM0
          1. Additional Pathologic Findings: Tumor, invasion to portal vein and duodenum is seen.
    • 2020-04-06 Lung flow volume curve
      • Mild restrictive pulmonary function impairment
    • 2022-04-06 2D transthoracic echocardiography
        1. Adequate LV systolic function with no regional wall motion abnormality at resting state
        1. Mild aortic, mitral and tricuspid regurgitation
        1. Thick IVS and LVPW
        1. Atheroma on ascending aorta
    • 2020-03-27 CT - lung/mediastinum/pleura
      • Finding
        • Visible abdomen
          • Soft tissue mass at pancreatic head about 4.1cm in largest dimension is found. In comparison with MRI dated on 2019-12-10, the lesion progressed.
          • The GB is well distended without soft tissue lesion
      • Imp:
        • Pancreatic head cancer, cT4N0M0, in progression.
    • 2019-12-27 2D transthoracic echocardiography
        1. Septal hypertrophy with indeterminate LV filling pressure and impaired RV relaxation; moderately dilated LA.
        1. Dilated LV with normal LV and RV systolic function.
        1. AV sclerosis with mild AR; mild MR.
        1. ild aortic root calcification with multiple protruding non-mobile atheromas (5-6 mm of thickness).
    • 2019-12-12 Surgical pathology Level V
      • clinical diagnosis
        • Malignant pancreas neoplasm, part NOS;
      • pathologic diagnosis
        • Pancreatic head, EUS/FNB — Adenocarcinoma
      • macroscopic examination
        • The specimen submitted consists of mutiple small pieces of gray-white soft tissue, labeled pancreatic head, measuring up to 3.5 x 0.1 x 0.1 cm. All for section.
      • microscopic examination
        • The sections show a picture of adenocarcinoma, composed of well to moderately differentiated polygonal to columnar neoplastic cells with occasional pleomorphic nuclei, arranged in papillary and duct-like structures. Desmoplastic stromal reaction and extensive tumor necrosis are evident.
    • 2019-12-11 Electronic Endoscopic Ultrasonography, EUS
      • position: pancreas
      • symptoms: elevated CA 19-9 and a 3-4 cm mass at the peri-panc head area   - Pre-EUS diagnosis: Suspected pancreatic cancer   - Endoscopic Findings: The major papilla looks normal.
          - EUS Findings
        • A 3.8x3.1 cm hyperechoic heterogeneous mass with one longitudinal cystic lesion within this tumor seen at the pancreatic head portion.
        • The mass revealed multiple small hypoechoic lesions inside. The MPD is not dilated. The vessels were not encased. The CBD measured about 8 mm in diameter.   - Diagnosis
        • Pancreatic tumor, head, S/P EUS/FNB perhaps SCN
    • 2019-12-10 MRI, MR cholangiography, MRCP
      • Imaging Report Form for Pancreatic Carcinoma
      • T4N0M0, stage III based on this MRI study
    • 2019-11-29 SONO - abdomen
      • diagnosis
          1. GB stone.
          1. pancreatic neck cystic lesion.
      • suggestion
          1. Visit GI/GS OPD if symptom revealed
          1. consider EUS for pancreatic cystic lesion
    • 2019-11-28 CPA - carotid phonoangiograph
        1. Mild atheromatous lesions in bilateral CCA bifurcatios, right ICA, right ECA and left CCA.
        1. Adequate total VA flow volume (108 ml/min).
        1. Increased RI in right VA, indicating distal stenosis.
    • 2019-11-28 Bone densitometry - hip
      • Hip BMD performed by DXA revealed:
        • Hip, BMD is 0.551 gms/cm2, about 2.4 SD below the peak bone mass (69%) and 0.2 SD below the mean of age-matched people (97%).
  • consultation
    • 2022-07-04 Family Medicine
      • Q
        • for share care or hospice care
        • This 75 y/o female, a pt of pancreatic head CA, ypStage IIB, ypT3N1 cM0, Dx in Dec 2019, s/p pre-op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 4 finishing in March 2020 & s/p pancreatico-duodenectomy on 20200408 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T from 20200608 to 20200704 & s/p post-Op adjuvant C/T wt FOLFIRINOX IV Q2W x 8 from July 2020 to Jan 2021 & palliative C/T Abraxane 100mg / m2 + Gem 900mg/m2 D1 & 8 Q3W x 13 since 2021-02 to 2022-05.
        • Owing to disease progression noted and we explained her poor condition to her family and DNR was consented. We need expertise to evaluate her condition thanks!
      • A
        • 75 y/ o lady advanced pancrease ca.
        • DNR + ECOG 3~4
        • GI bleeding pulmonism embolim
        • Our share care would follow up. Thanks for consultation.
    • 2022-06-16 Hemato-Oncology
      • Q
        • For evaluation of current condition and the future treatment plan of pancreatic cancer
        • This is a 75 y/o patient with pancreatic head cancer who is currently hospitalized for the treatment of recurrent pulmonary embolism.
        • Please kindly assist to evaluate the patient and advise if she can proceed with palliative chemotherapy, and if DNR is a viable option should her condition worsen during the course of current treatment.
      • A
        • Impression
            1. Recurrent pulmonary embolism, favor cancer related
            1. Pancrease Adenocarcinoma, ypStage IIB, ypT3N1 cM0, Dx in Dec 2019, s/p pre-op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 4 finishing in March 2020 & s/p pancreatico-duodenectomy on 4/8 20 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T from 6/8 20 to 7/4 20 & s/p post-Op adjuvant C/T wt FOLFIRINOX IV Q2W x 8 from July 2020 to Jan 2021 & palliative C/T Abraxane 100mg / m2 + Gem 900mg/m2 D1 & 8 Q3W x 13 since 2021.02 to May 2022. Suspected recurrent with liver and LLL meta and Some LNS at retroperitoneum with SMV encasement. (abdominal 20200310 amd 20200607 CT), apply 3rd lines palliative chemotherapy with Onivyde (80mg/m2, give 120mg, IVF Q2W x 6) plus HDFL.
        • Suggestion
            1. Thanks for your consultation. We will see the patient and discuss with further treatment.
            1. Treat pulmonary embolism as your expertise. May consider check other etiology of hypercoagulation although we favor cancer related
    • 2022-06-14 Cardiology
      • Q
        • dyspnea on exertion for 3 days, desaturation was found yesterday at home
        • no chest pain, no odynophagia, no GI symptoms, no skin rash, no dysuria
        • Went hema opd today for chemotherapy f/u, transferred to covid-19 opd for suspected covid-19
        • 20220607 CT Pancreatic head cancer s/p operation. Partial thrombosis of IVC; General subcutaneous edema. Small amount ascites. Bil. pleural effusions. Small patchy densities (0.5cm, 0.6cm) at LLL. A poor enhancing nodule (2.3cm) at S6 of liver. Some LNS at retroperitoneum with SMV encasement.
        • PHx: pancreatic cancer, HTN, pulmonary embolism
        • NKDA
        • 2022-02-11
          • 1: Acute pulmonary embolism, bilateral
          • 2: Acute respiratory failure with hypoxia
          • 3: Inferior vena cava thrombus with pulmonary embolism and bialteral upper lobe patch.
          • 4: Circumferential venous thrombosis at right ostial to proximal Superficial femoral vein. with adequate recanalization
          • 5: pancreatic cancer of adenocarcinoma , ypStage IIB, ypT3N1 cM0 post operation and concurrent chemoradiotherapy
          • 6: Pneumonia, bilateral lung by sputum culture grewed mix flora
      • A
        • O
          • Lab Hb 10.2, WBC 6660, PLT 191k, Cre 0.90, K 4.2, ALT 23, CRP 1.97, NTproBNP 5397, hsTnI 131.5, CKMB 1.6, INR 1.68, Ddimer 7534
          • CXR 20220614 borderline heart size
        • Impression
          • Pulmonary embolism, bilateral, noted since 2022/02, –> still residual thrombi
          • Pancreatic head cancer, IVC thrombosis
          • Ascites, increasing than before (by CT images comparision)
          • right lower limb DVT in 2022/02
        • Suggestion
            1. Keep NOAC as OPD Or give clexane 1mg/kg sc Q12h
            1. If unstable hemodynamic status or desaturation is concerned, May book ICU care.
            1. Pulmonary embolism treatment effect is related to underlying cancer status
    • 2022-03-29 Dermatology
      • Q
        • Under the impression of left leg cellulitis. She was admitted to Infection’s ward for further evaluation and treatment on 20220326. For bilateral leg scaly and vesicle lesions, we need ypur expertsie on evaluation or some suggestion. Thank you very much!
      • A
        • This patient suffered from some erytheamtous papules on bil legs for days.
        • Imp: Pigmented purpuric dermatosus
        • Suggestion:
            1. Sinpharderm * 1 tube/bid
            1. Topsym cream * 3 tubes/bid
    • 2022-02-10 Cardiology
      • A
        • I was consulted for pulmonary embolism
        • O
          • CT scan documented
          • Cr 0.8
        • Suggestion:
            1. ICU admission
            1. Clexan 1mg/kg Q12H SC if no contraindication
    • 2022-04-10 Gastroenterology
      • A case of pancreatic cancer who request post-op nutrition support.
        • General appearance: ill looking
        • GI tract: Whipple on 20220408
        • Feeding: Sip water with NG decompression
        • Allergy: NKA
        • Past history: DM
        • Nutrition assessment:
          • BH 148cm BW 55.6kg
          • IBW 48.2kg 115% IBW, BMI 25.4, ABW 50kg
          • BEE (based on ABW) 1070kcal, TEE 1670kcal
        • Lab data: GOT 160, GPT 232, K 3.5
        • 20220409 Blood sugar: 408-310-262-218-204
      • According to the patient’s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN use suggestion
        • DC YF5 1000ml QD (RI 10U each bottle)
        • DC SMOFkabiven peri 1440ml QD
        • SMOFkabiven central 1477ml QD, 61.5ml/hr
        • Lyo-Povigent 4ml/QD(add in TPN)
        • Addaven 10ml/QD(add in TPN)
        • RI 26U/QD(add in TPN)
        • KCL 5ml/QD(add in TPN)
      • Items to be monitored when in PN use
          1. Do not mix other drugs with TPN
          1. Check BW QW5 and record I/O Q8H
          1. Check one touch Q6H*2days, if stable QD check
          1. Please control BS <200 mg/dl with RI sliding scale
          1. QW1 check CBC/DC
          1. QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
          1. if TPN is not sufficient, use YF5 or D10W
  • chemoimmunotherapy
    • 2022-05-30 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
    • 2022-05-10 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
    • 2022-04-26 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
    • 2022-04-12 - nal-paclitaxel 125mg/m2 180mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
    • 2022-03-22 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1300mg 0.5hr
    • 2022-01-18 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2022-01-04 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-12-21 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-12-07 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-11-23 - nal-paclitaxel 125mg/m2 160mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-10-19 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-10-12 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-09-14 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-09-07 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-08-24 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
    • 2021-08-17 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
    • 2021-08-03 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
    • 2021-07-20 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
    • 2021-05-18 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
    • 2021-05-11 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1250mg/m2 1700mg 0.5hr
    • 2021-04-27 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-04-20 - nal-paclitaxel 125mg/m2 170mg 0.5hr + gemcitabine 1000mg/m2 1400mg 0.5hr
    • 2021-04-06 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
    • 2021-03-30 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
    • 2021-03-16 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
    • 2021-02-23 - nal-paclitaxel 100mg/m2 140mg 0.5hr + gemcitabine 900mg/m2 1200mg 0.5hr
    • 2021-01-08 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3950mg 46hr
    • 2020-12-18 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • 2020-11-24 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • 2020-10-30 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3920mg 46hr
    • 2020-10-08 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3920mg 46hr
    • 2020-09-18 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3870mg 46hr
    • 2020-08-24 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 570mg 2hr + fluorouracil 2800mg/m2 4000mg 46hr
    • 2020-07-29 - oxaliplatin 40mg/m2 50mg 2hr + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 570mg 2hr + fluorouracil 2800mg/m2 4000mg 46hr
    • 2020-06-29 - fluorouracil 225mg/m2 320mg D1-5 (CCRT)
    • 2020-06-26 - fluorouracil 225mg/m2 320mg D1 (CCRT)
    • 2020-06-22 - fluorouracil 225mg/m2 320mg D1-3 (CCRT)
    • 2020-06-15 - fluorouracil 225mg/m2 320mg D1-5 (CCRT)
    • 2020-06-08 - fluorouracil 225mg/m2 320mg D1-5 (CCRT)
    • 2020-03-09 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3400mg 46hr
    • 2020-02-18 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3400mg 46hr
    • 2020-02-04 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3400mg 46hr
    • 2020-01-07 - oxaliplatin 60mg/m2 90mg 2hr + leucovorin 400mg/m2 600mg + irinotecan 90mg/m2 100mg 2hr + fluorouracial 1200mg/m2 3600mg 46hr

[assessment]

  • Ceftriaxone for this CrCl >15 mL/min patient, no dosage adjustment is necessary.
  • In patients (with community-acquired pneumonia in the absence of neutropenia and immunosuppressive therapy) requiring hospital admission, monotherapy with a respiratory fluoroquinolone or combination therapy with a macrolide plus either ceftriaxone, cefotaxime, or ertapenem is recommended.
  • 2022-08-01 eGFR 31.79.
    • For patients with eGFR 30 to 50 mL/minute/1.73 m2, spironolactone is recommended to be initialized at 12.5 mg once daily or every other day; may double the dose every 4 weeks if serum potassium remains <5 mEq/L and renal function is stable, up to a maximum target dose of 25 mg/day.
  • 2022-08-01 Creatinine 1.67 mg/dL. The following oral tranexamic acid adjustments are based on a usual recommended dose of 10 to 15 mg/kg or 1 to 1.5 g 3 to 4 times daily.
    • Serum creatinine >=1.4 to <2.8 mg/dL (>=120 to <250 micromol/L): Administer usual dose twice daily.

701432312

220801

{lung adenocarcinoma and esophageal adenocarcinoma}

[Past History]

  • past history
    • C5/6 disc herniation s/p OP on 2021/10/21 and TIA in 2022/03
    • LLL adenocarcinoma s/p VATS segmentectomy on 2022/06/21
    • DM(+) in 2021/05
      • Galvus Met 50mg & 500mg 1# po QD
    • HTN(+) in 2010
      • Pravafen 40mg & 160mg 1# po QN
      • Exforge F.C 5mg & 160mg 1# po QD
      • Bokey 1# po QD
  • lab data
    • 2022-07-15 Anti-HBc Reactive
    • 2022-07-15 Anti-HBc-Value 2.41 S/CO
    • 2022-07-15 Anti-HBs 5.12 mIU/mL
    • 2022-07-15 HBsAg Nonreactive
    • 2022-07-15 HBsAg Value 0.00 IU/mL
    • 2022-07-15 Anti-HCV Nonreactive
    • 2022-07-15 Anti-HCV Value 0.09 S/CO
  • exam finding
    • 2022-06-21 CT - lung
      • LLL cacner, cT2bN1M1a, stage IVA
      • Esophagus (Lower 1/3), cT3N3M0, stage IVA.
    • 2022-06-10 Pathology
      • esophagus endoscopic biopsy — adenocarcinoma, poorly differentiated, primary or secondary,
      • the esophagus lower third, endoscopic biopsy showed metastatic adenocarcinoma, poorly differentiated, suspicious for gastric or intestinal origin.
    • 2022-05-31 Whole body PET scan
      • LLL tumor and lower esophageal tumor.
    • 2022-05-24 Whole body bone scan
      • no bone metastasis.
    • 2022-05-23 CT - brain
      • no brain metastasis.
    • 2022-05-19 Pathology
      • LLL tumor CT Guide biopsy — adenocarcinoma, poorly differentiated, lung origin.
    • 2022-05 CT at DaLin TzuChi Hospital
      • a distal esophageal tumor and another LLL lung tumor
  • surgical operation
    • 2022-06-21 VATS LLL S10 segmentectomy + mediastinum lymph node dissection
      • pathology showed Adenosquamous carcinoma, poorly differentiated, pT2aN2
      • ICH stains showed CDX2 (EPR2764Y/Zeta, 100X), TTF-1 (SPT24/Leica, 250X), P40 (polyclonal/Zytomed, 100X).
  • radiotherapy
    • 2022-07-21 ~
      • Plan to deliver 4500 cGy/ 25 fx to the L/2 esophagus and adjacent lymphatic drainage area.
      • Then boost the esophageal tumor and celiac LAPs to 5040 cGy/ 28 fx.
      • The preOP (lung ca.) tumor bed: around 5600 cGy/ 28 fx.
  • chemoimmunotherapy
    • 2022-07-26 - paclitaxel 50mg/m2 80mg 3hr D1 + carboplatin AUC2 150mg 2hr D2
    • 2022-07 plan
      • adjuvant therapy for lung ca.
      • neo-adjuvant therapy for eso. ca

[note]

  • HBV ref: https://cdn.who.int/media/docs/default-source/searo/hiv-hepatitis/training-modules/08-hbv-serological-markers.pdf
    • HBV serological markers
      • HBsAg (hepatitis B surface antigen)
        • Hallmark of infection
        • Positive in the early phase of acute infection and persists in chronic infection
        • Quantification of HBsAg is a potential alternative marker of viraemia and it is also used to monitor the response to antiviral treatment
      • Anti-HBc IgM (hepatitis B core antibody)
        • IgM subclass of anti-HBc and observed during acute infection (used to differentiate between acute and chronic HBV infection)
        • Might become positive during severe exacerbation of chronic infection
      • Anti-HBc (total)
        • Develops around 3 months after infection (most constant marker of infection)
        • Total anti-HBc (IgM, IgA and IgG) indicates resolved infection
      • HBeAg (hepatitis B e antigen)
        • Viral protein usually associated with high viral load and high infectivity
      • Anti-HBe (hepatitis B e antibody)
        • Antibody to HBeAg usually indicates decreasing HBV DNA
        • But present in the immune-control and immune-escape phases
      • Anti-HBs (hepatitis B surface antibody)
        • Neutralizing antibody that confers protection from infection
        • Recovery from acute infection (with anti-HBc IgG)
        • Immunity from vaccination
    • Hepatitis B surface antigen and antibody
      • HBsAg
        • First marker to appear following HBV infection
        • Positivity indicates presence of virus in a person’s body
        • Acute infection: Disappears within 6 months
        • Chronic infection: Persists for several years (lifelong in most)
        • Measurement of HBsAg concentration is being tried as a potential alternative marker of viremia and to monitor response to treatment, but still not well accepted
      • Anti-HBs
        • Antibody to HBsAg
        • Is a neutralizing antibody and confers protection from infection
        • Appears following clearance of acute infection
        • Does not develop in those who have chronic infection
        • Also develops in response to hepatitis B vaccine
        • Presence indicates immunity following acute infection or vaccination
        • Anti-HBs titre >10 mIU/mL is considered to be protective
        • Persists for several years (often lifelong) after infection, but disappears in a few years after immunization
    • Hepatitis B core antigen and antibody
      • HBcAg
        • An internal component of the virus
        • Present in the nucleus of infected cells
        • But, does not appears in infected person’s blood
        • Not tested in clinical settings
        • Hepatitis B vaccine does not contain this antigen
      • Anti-HBc
        • Develops in all those who get HBV infection, whether acute or chronic
        • Does not develop after immunization
        • Two types IgM and IgG
      • IgM anti-HBc
        • Appears following acute infection, and persists for up to ~6 months
        • Hence: presence indicates recent (acute) infection
        • Occasionally, detectable (in low amount) during severe exacerbation of chronic infection
      • IgG (or Total) anti-HBc
        • Develops soon after IgM anti-HBc
        • Most constant marker of exposure (current or past infection)
        • Positive total anti-HBc (IgG, IgM) with negative IgM anti-HBc in HBsAg negative indicates resolved infection
    • Hepatitis B e-antigen and antibody
      • HBeAg
        • Produced in cells where virus is actively replicating, and is secreted into the plasma
        • Usually its presence indicates high viral load and high infectivity
        • Its absence indicates lower viral load, lower HBV DNA level. But, in some, may be absent despite high viral load (due to viral mutation)
        • Associated with high risk of HBV transmission following exposure, such as needle-stick injury, mother-to-child transmission, etc
      • Anti-HBe
        • Indicates host immune response against HBeAg
        • Usually associated with reduced viral replication, lower HBV DNA titer and reduced infectivity
        • But also present in those in HBeAg-negative viral mutation
      • HBV DNA
        • Direct and accurate marker of HBV replication
        • Serum level seems to correlate with the risk of disease progression
        • Used to decide need for anti-viral drugs
        • Also used to monitor efficacy of anti-viral drug treatment
        • Unit: almost 5 copies = 1 IU

[assessment]

  • Double malignancies: 1) LLL adenocarcinoma s/p VATS LLL S10 segmentectomy and mediastinum lymph node dissection on 2022-06-21; 2) Esophageal (lower 1/3) adenocarcinoma.
  • Documented treatment plan: adjuvant therapy for lung ca. and neo-adjuvant therapy for eso. ca.
  • Carboplatin and paclitaxel are drugs that can be used in regimens for both lung cancer and esophageal cancer. NCCN guidelines describe regimens containing these two drugs:
    • For NSCLC: carboplatin AUC 6 day 1, paclitaxel 200mg/m2 day 1, every 21 days for 4 cycles.
    • For Eso ca: carboplatin AUC 2 day 1, paclitaxel 50mg/m2 day 1, weekly for 5 weeks.
  • The latter (lower doses with higher frequency administration) is initialized on 2022-07-26.
  • Underlying conditions including T2DM and HTN.
    • There is good control of blood sugar levels during this hospitalization.
    • A number of data points between 2022-07-29 and 2022-07-31 showed hypotension events (SBP < 100, DBP < 60). If the hypotension occurs again, please hold Exforge (amlodipine + valsartan) temporarily.

701341214

220729

{prevent the patient from potential drug interaction: Dasatinib / Inhibitors of the Proton Pump (PPIs and PCABs)}

  • Pantoprazole (PPI) might decrease the serum concentration and efficacy of dasatinib (both drugs were prescribed as QD administratered and the latter is listed as an self-carried item in active prescription).
  • It is recommended not to administer proton pump inhibitors (PPIs) or potassium-competitive acid blockers (PCABs) with dasatinib. Coadministration of these agents and dasatinib might reduce dasatinib concentrations and efficacy.
  • Please consider antacids taken 2 hours before or after dasatinib administration if acid-reducing therapy is needed. As an example, shift dasatinib from QD to QN.

700370302

220727

  • Thrombocytopenia is treated with eltrombopag.

701433496

220727

  • exam findings
    • 2022-07-22 CXR
      • S/P port-A implantation.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
      • Hypoinflation of both lung is noted.
    • 2022-07-18 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
      • Hypoinflation of both lung is noted.
      • A nodular opacity projecting in the left upper lung is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
    • 2022-07-21 SONO - abdomen
      • Diagnosis
        • Hepatic tumors, multiple, bilateral lobe, suspected metastasis
        • Gall stones
        • Splenic cysts
        • Small amount ascites
      • Suggestion
        • Please correlate with other image study
    • 2022-07-18 Patho - colon biopsy
      • DIAGNOSIS:
        • Colon, SD junction, biopsy — Adenocarcinoma, moderately differentiated
      • MICROSCOPIC DESCRIPTION:
        • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
        • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2022-07-18 Colonoscopy
      • Diagnosis
        • Probable colon cancer with partial obstruction, 35cm AAV, probable at SD junction, s/p biopsy
        • Incomplete study, poor colon preparation.
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2022-07-15 ECG
      • Sinus tachycardia with Premature supraventricular complexes
      • Low voltage QRS
      • Borderline ECG
    • 2022-04-27 CT (Cardinal Tien Hospital)
        1. consider sigmoid colon malignancy, involving length is approximately 6.2cm, imaging staging favored T4bN1bM1b if pathological proven malignancy.
        1. Multiple hepatic and splenic tumors, like metastases.
  • consultation
    • 2022-07-20 Colorectal Surgery
      • Q
        • This 88 y/o female has history of DM, HTN under medical control and suspect colon cancer with liver metastases associated chronic diarrhea for one month under symptom control. This time, according to the families, the patient was found with fever and chillness for one day, so she was sent to our ER for help on 20220712, vital signs showed BP:121/57; PR:107; BT:38.5; RR:19; EKG showed Sinus rhythm with Premature atrial complexes; PE showed unremarkable. Lab showed Covid-19 rapid screen: positive, WBC:14.92, Neutrophil:81.7%, CRP:7.9, Lactic acid:3.1, hs-TnI:114.2, Hb:6.5, MCV:70fL, RDW-CV:22.3%, Na:133, K:2.7, BUN/Cr:19/1.01, U/A with bacteria:1+ but without pyuria; CXR showed both lower lobes infiltration.
        • So, under impression of 1.) Sepsis, favor Covid-19 infection with secondary bacterial pneumonia; 2.) suspect colon cancer with liver metastases for one month; 3.) Severe microcytic Anemia, she is admitted to our isolation ward for further care on 20220712. - After admission, empirical antibiotic with Brosym, steroid agent with Decan injection were given for pneumonia treatment since 20220712. Urine culture showed mixed growth. Pending one set of blood culture and sputum culture. Antivirus agent with Remdesivir injection since 7/13-7/17 for treatment. We consulted Hospice for colon cancer terminal on 7/13. We consulted Oncologist for colon cancer terminal survey on 7/15. DNR was signed on 7/15. She is transfer to Oncologist ward for survey on 20220715.
        • At ONC ward, we had explained the current condition to family (third daughter-in-law).
        • CT of abdominal was performed on 20220427 at Cardinal Tien Hospital revealed 1) consider sigmoid colon malignancy, involving length is approximately 6.2cm, imaging staging favored T4bN1bM1b if pathological proven malignancy. 2) Multiple hepatic and splenic tumors, like metastases.
        • Colonscopy was arrange on 20220718 showed A huge ulcerative tumor with partial obstruction of the colon was noted at 35cm AAV, probable at SD junction, s/p biopsy. We need your expertise for evaluation, thanks.
      • A
        • O
          • Abdomen: soft, mild distended, no tenderness, no peritoneal sings
          • pass flatus(+)
          • diarrhea(+)
          • SOB(+)
        • A: S-colon cancer with multiple metastases of liver and spleen, stage IVb (incurable)
        • P:
            1. Diverting colostomy (under general anesthesia) may be considered if total obstruction symptoms/signs developing
            1. Surgical and anesthesia risk is very high due to very old age and terminal cancer stage and comorbidities
            1. We had discussed her disease condition to her family and she can understand
            1. Suggest hospice and palliative treatment
    • 2022-07-15 Hemato-Oncology
      • A
        • Impression:
            1. Suspect colon cancer? AAD (Against Advise Discharge) from Cardinal Tien Hospital
            1. DM, HTN under medical control
        • Suggestion:
            1. We had phone call her daughter-in-law and discuss with further care. They agree arrange colonscopy for tissue proof (for apply IC Cards for Severe Illness) after transfer to ordinary ward.
            • In addition, Daughter-in-law agreed to go to Cardinal Tien Hospital to apply for medical records and image CD after transfer to ordinary ward.
            1. Thanks for your consultation.

[assessment]

  • Nasogastric tubes can be used to administer all oral medications in active prescriptions.
  • The patient has applied for hospice care.
  • F/S recorded low blood sugar levels
    • 2022-07-26 06:19 56 mg/dL
    • 2022-07-26 06:18 60 mg/dL
    • 2022-07-21 06:24 50 mg/dL
  • A hypoglycemic event is more likely to occur in the early morning, and it should be observed if there is a difference in carbohydrate intake or consumption from the night before to the next day.

700301518

220726

  • diagnosis
    • 67 y/o male, a pt of NSCLC at LLL wt lung to lung mets & liver, & adrenal mets & L neck LNs mets Dx in Dec 2021.
    • suffered from initial presentation of L neck LN enlargement at level II & III since Oct 2021.
    • This is a 67 year old man who has the history of liver cirrhosis, acute cholecystitis s/p cholecystectomy, old CVA with right hemiparesis, and non-small-cell lung cancer at left lower lung with lung to lung mets & liver, & adrenal mets & L neck LNs mets Dx in Dec 2021
  • lab data
    • 2022-01-10 PD-L1 Immunostaining Result (28-8)
      • Labeled as: S21-18526
      • Tumor type: Head and neck cancer, squamous cell carcinoma
      • Tumor cell (TC) staining assessment: TC >= 50%
      • Percentage of 28-8 expressing tumor cells (%TC): 65%
    • 2021-12-30 PD-L1 Immunostaining Result (22C3)
      • Labeled as: S2021-18526
      • Tumor Proportion Score (TPS) assessment: TPS >= 50%
      • Tumor Proportion Score (TPS): 55%
  • exam finding
    • 2022-07-25 CXR
      • S/P Port-A infusion catheter insertion.
      • Multiple nodules at bil. lungs.
      • Normal appearance of trachea and bil. main bronchus.
      • Atherosclerosis of the aorta.
      • S/P operation with retention of surgical clips.
      • Old frcture of bil. ribs.
      • Suggest clinical correlation.
    • 2022-07-04 CT - lung/mediastinum/pleura
      • Findings
        • Lungs:
          • significant inecrease in size of LLL anteromedial basal tumor (71mm in longest axial dimension) and increase in size and number of multiple nodules of variable sizes in both lungs as compared with CT on 2022/03/28
          • centrilobular emphysema in both upper lobes
        • Mediastinum and hila: enlarged LN at Rt paratracheal space, and subcarina
          • Vessels: moderate coronary arterial calcification
          • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
          • Central pulmonary arteries: normal caliber. .
          • Heart: normal in size of cardiac chambers.
        • Pleura: minimal effusion.
        • Chest wall and visible lower neck: progression of enlarged left neck LAPs, level II-III-IV compared with CT on 2022/03/28
        • Visible abdominal contents: s/p cholecystectomy. pneumobilia in left lobe liver and increase in size and numbers of ill-defined heterogeneous tumors in liver and Rt adrenal tumor compared with CT on 2022/03/28.
          • unremarkable of the pancreas, and kidneys. bile ducts: dilatation of CBD and CHD. mild splenomegaly.
          • no enlarged lymph node.
        • Extensive atherosclerotic change of the abdominal aorta.
        • Visualized bones: extensive spondylosis.old fracture of many Lt ribs and Rt and Lt clavicles.
      • Impression:
        • LLL cancer T4N3M1c, in progression as compared with previous CT study on 2022/03/28
    • 2022-07-04 CXR + Lat. LT
      • S/P port-A implantation.
      • Primary lung cancer in LLL become smaller in size.
      • Few nodular opacity projecting in the left lower lung are noted. Please correlate with CT.
      • Atherosclerotic change of aortic arch
      • Old fracture of bilateral clavicle and left ribs.
      • Spondylosis of the T-spine
    • 2022-06-06 SONO - abdomen
      • Diagnosis
        • poor echo window: please see discription
        • Liver tumor: (suspected HCC?)
        • Liver cirrhosis (incomplete exam of liver), splenomegaly
        • GB sac not seen
        • pancreas not shown
      • Suggestion
        • suggest further imaging study
    • 2022-05-03 KUB
      • s/p cholecystectomy
      • Unremarkable psoas shadows
      • Degenerative change of the lumbar spine
      • s/p right total hip replacement
    • 2022-05-03 CXR
      • Mass lesions in both lung fields
      • Bilateral clavicle and rib old fractures
    • 2022-05-03 ECG
      • Sinus tachycardia
    • 2022-05-03 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • No active bleeder nor coffee ground material was noted during this exam.
        • Suboptimal study due to food residual retention
        • Reflux esophagitis LA Classification grade A (minimal)
        • Superficial gastritis
      • Suggestion
        • 2nd look endoscopy is warranted if active bleeding sign or persisted tarry stool.
    • 2022-03-28 CT - lung/mediastinum/pleura
      • Findings
          1. Lungs:
          • decrease in size of LLL anteromedial basal tumor (33 mm in longest axial dimension) and multiple nodules of variable sizes in both lungs, and resolution of LLL GGO as compared with CT on 2021/12/06.
          • centrilobular emphysema in both upper lobes
          1. Mediastinum: regression of enlarged LN at Rt paratracheal space.
          1. Hila: no enlarged LN.
          1. Vessels: moderate coronary arterial calcification Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta. Central pulmonary arteries: normal caliber.
          1. Heart: normal in size of cardiac chambers.
          1. Pleura: no effusion.
          1. Chest wall and visible lower neck: regression of enlarged left neck LAPs, level II-III-IV.
          1. Visible abdominal contents: s/p cholecystectomy. pneumobilia in left lobe liver and increase in size an ill-defined heterogeneous tumor in S6 (76x85 mm) and stationary of a 16 mm Rt adrenal tumor. unremarkable of the spleen, pancreas, and kidneys. bile ducts: dilatation of CBD and CHDno enlarged lymph node.
          1. Extensive atherosclerotic change of the abdominal aorta.
          1. Visualized bones: extensive spondylosis.old fracture of many Lt ribs and Rt and Lt clavicles.
      • Impression:
        • LLL cancer T4N3M1c, regression of primary LLL tumor and metastatiuc lung tumors, stationary of Rt adrenal tumor, and metastatic LAP at mediastinum and neck, but increase in size ofmetastatic hepatic tumor as compared with previous CT study on 2021/12/06
    • 2022-03-14 SONO - abdomen
      • Diagnosis
        • poor echo window: please see discription
        • Liver tumor: (suspected HCC?)
        • Liver cirrhosis (incomplete exam of liver), mild splenomegaly
        • GB sac not seen
      • Suggestion
        • suggest further imaging study
    • 2021-12-24 PD-L1 (SP142)
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
        • S2021-19387
          • Tumor type: squamous cell carcinoma
          • Tumor location: soft tissue, right neck
          • Testing assay: SP142 Assay (Ventana)
          • Testing platform: BenchMark XT
          • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
            Control slide result: Pass,
            Adequate tumor cells present (>=50 viable tumor cells): Yes,
        • Result:
            1. Tumor cell (TC) staining assessment:
              1. TC category: TC < 1%
            1. Tumor-infiltrating immune cell (IC) staining assessment:
              1. IC category: IC < 1%
        • Note:
            1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
            1. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2021-12-13 Patho - lymphnode biopsy
      • DIAGNOSIS:
        • Soft tissue, left neck, sono-guide biopsy — squamous cell carcinoma, moderately differentiated, origin?
      • MICROSCOPIC DESCRIPTION:
        • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma. No keratinization is seen.
        • The immunohistochemical stains reveal p40(+), TTF-1(-), Napsin A(-), and CD56(-). No lymphoid tissue is seen.
        • Please correlate with the clinical presentation and image study for tumor origin.
    • 2021-12-07 Whole body PET scan
        1. A prominent glucose hypermetabolic lesion in the lower lobe of left lung. Primary lung malignancy should be considered. Please correlate with other clinical findings for further evaluation.
        1. Glucose hypermetabolism in multiple left neck level II to V lymph nodes and in the right pulmonary hilar region, compatible with metastatic lymph nodes.
        1. Glucose hypermetabolism in multiple focal area in bilateral lung fields, in some focal areas in the liver and in some bones as mentioned above, suggesting multiple liver, lung and bone metastases.
        1. Mild glucose hypermetabolism in the right adrenal gland. The nature is to be determined (adrenal hyperplasia or adenoma? other nature?). Please also correlate with other clinical findings for further evaluation.
    • 2021-12-06 CT - lung/mediastinum/pleura
      • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value), N:N3(N_value), M:M1c(M_value), STAGE:IVB
    • 2021-11-13 CT - neck
      • Multiple enlarged left neck LAPs, level II-III-IV.
      • Left carotid artery encasement by the LAPs were found.
      • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
    • 2021-11-01 L-N aspiration
      • DIAGNOSIS:
        • Left neck mass— Carcinoma
      • MICROSCOPIC DESCRIPTION:
        • Smears show cohesive atypical tumor cells with nuclear hyperchromasia, pleomorphism and high N/C ratio.
    • 2021-10-29 SONO - head and neck soft tissue
      • Clinical impression/intent: left multiple neck mass (level 2-4)
      • Sonographic impression: left multiple neck mass with extra-capusular extension, suspected metastasis.
    • 2021-04-05 MRI - MR Cholangiography, MRCP
      • S/P cholecystectomy. A filling defect at distal CBD (1.4cm) with biliary dilatation suspected stone.
      • Splenomegaly.
      • Dilatation of p-duct (5.1mm).
    • 2021-03-15 CT - abdomen, pelvis
      • S/P cholecystectomy.
      • Suspected cholangitis and distal CBD stone.
    • 2021-01-09 Hip joints bilat.
      • S/P right THR without evidenced prothesis loosening.
    • 2021-01-09 CT - abdomen, pelvis
      • Suspected distal CBD stone (4mm). Mild dilatation of IHD (intrahepatic duct) suspected cholangitis. Liver cirrhosis with splenomegaly.
    • 2021-01-08 ECG
      • Sinus tachycardia
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2020-10-05 SONO - neurology
        1. Mild (to moderate) atheromatous lesions in R CCA bifurcation.
        1. Relatively smaller caliber with decreased flow in R cervical VA compared with L VA.
        1. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
        1. Poor bilateral temporal windows for transcranial insonation.
        1. Suspicious mass lesion in left thyroid gland.
    • 2019-05-10 Cardiac ultrasound, M-mode Echo, Doppler color flow mapping
        1. Adequate LV systolic function with normal resting wall motion
        1. Septal hypertrophy; LV diastolic dysfunction, Gr 1
        1. Trivial MR and mild TR
        1. Preserved RV systolic function
    • 2019-05-09 Bronchodilator Test, Flow-volume curve
      • Moderate restrictive ventilatory impairment
      • Not significant bronchodilator reversibility
    • 2019-05-08 CT - abdomen
      • Distal CBD stone with biliary tree obstruction.
      • Liver cirrhosis.
    • 2019-05-08 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • Patent airway is found.
      • Senile fibrotic change is noted at lung fields.
    • 2018-05-28 Hip joints RT
      • S/p Total hip replacement over right side.
      • The alignment of the bony structure after procedure is satisfactory.
    • 2018-05-22 MRA - brain
      • Brain atrophy with multiple old lacunar brain infarcts.
      • Old hemorrhage in left thalamus. Abnormal signal intensity in bilateral middle cerebellar peduncles, nature to be determined.
    • 2018-05-21 Color transcranial Doppler, Dopscan, Carotid phonoangiograph (CPA)
        1. Mild to moderate atheromatous lesions in R CCA bifurcation; mild atheromatous lesions in L CCA bifurcation.
        1. Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
        1. Poor bilateraltemporal windows for transcranial insonation.
    • 2018-05-16 CT - brain
      • Brain atrophy and old infarcts.
  • chemoimmunotherapy
    • 2022-06-20 - cisplatin 60mg/m2 1.5hr
    • 2022-05-30 - cisplatin 60mg/m2 1.5hr
    • 2022-05-09 - cisplatin 60mg/m2 1.5hr
    • 2022-04-11 - cisplatin 60mg/m2 1.5hr
    • 2022-03-21 - gemcitabine 1000mg/m2 30min
    • 2022-03-07 - gemcitabine 1000mg/m2 30min + cisplatin 60mg/m2 1.5hr
    • 2022-02-14 - gemcitabine 1000mg/m2 30min
    • 2022-02-07 - gemcitabine 1000mg/m2 30min + cisplatin 60mg/m2 1.5hr
    • 2022-01-17 - gemcitabine 1000mg/m2 30min
    • 2022-01-04 - gemcitabine 1000mg/m2 30min + cisplatin 50mg/m2 1.5hr

[assessment]

  • Lab data 2022-07-26: Procalcitonin (PCT) 1.73ng/mL, CRP 21.88mg/dL
  • The initial empiric therapy for fever and neutropenia in high-risk patients could be cefepime, imipenem/cilastatin, piperacillin/tazobactam, and ceftazidime. The administration of ceftazidime 2000mg Q8H IVD has been ongoing since 2022-07-26. Results of blood and urine cultures have not yet been released.
  • If atypical bacteria are suspected, azithromycin, doxycycline, or fluoroquinolones might be an optional add-on. The use of fluconazole as a prophylactic measure might also be considered for anticipated mucositis.

701164228

220726

  • diagnosis
    • 1: Endometroid carcinoma, FIGO grade 3, of the uterine endometrium, AJCC 8 th edition, Pathology stage: pT3aN0(cM0); stage IIIA; FIGO stage IIIA, s/p staging on 2022-02-07.
    • 2: Right breast Invasive carcinoma post breast conserving therapy, pT2N1a(sn)M0, stage IIB,
    • 3: Chronic viral hepatitis B without delta-agent
  • exam finding
    • 2022-06-22 SONO - abdomen
      • Diagnosis
        • Fatty liver, marked
        • Liver cysts
        • Chronic kidney disease with renal calcifications
        • Left renal stone
        • (suboptimal echo window)
      • Suggestion
        • OPD follow-up
    • 2022-02-08 Patho - uterus (with or without SO) neoplastic
      • Pathologic Diagnosis
        • Uterus, endometrium, ATH — Endometroid carcinoma, FIGO grade 3
        • Fallopian tube, right, BSO — Involved by carcinoma
        • Lymph nodes, pelvic and para-aortic, bilateral, BPLND + PALND — Negative for malignancy (0/39)
        • AJCC 8 th edition, Pathology stage: pT3aN0; stage IIIA; FIGO stage IIIA; if cM0
      • Macroscopic Examination
        • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection
      • Microscopic Examination
        • Histologic Type: Endometroid carcinoma
        • Histologic Grade: FIGO grade 3
        • Adenomyosis: Not identified
        • Depth of Tumor Invasion: Tumor invading more than half of myometrium
        • Cervical Stromal Involvement: Not identified
        • Other Tissue/Organ Involvement: Tumor involving right fallopian tube
        • Peritoneal/Ascitic Fluid: Not submitted
        • Margins: Uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 1.5 cm
        • Lymphvascular Invasion: Present
        • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/39)
        • AdditionalPathologic Findings
          • Cervix: Chronic cervicitis with squamous metaplasia
          • Myometrium: Leiomyoma
          • Ovary, right: No remarkable change
          • Ovary, left: No remarkable change
          • Fallopian tube, left: Chronic salpingitis
          • Omentum: No remarkable change
    • 2022-02-08 Cytology - ascites
      • ASCITES: suspicious for malignancy
      • Smears show lymphoid cells, and few suspicious cells with elongated
    • 2022-01-17 MRI - pelvis
      • suspected endometrial malignancy with lymph nodes metastasis (paraaortic region).
        • right parametrial soft tissue tumors, parametrial lymph nodes metastasis or tumor seeding? cstage T3N2M0.
      • uterine tumors, suspected myomas.
      • suspected liver cysts.
    • 2022-01-06 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, TCR — Endometrioid adenocarcinoma
      • Microscopically, sections show endometrioid adenocarcinoma characterized by proliferation of neoplastic ells arranged in cribrinform to solid architecture and invasive growth pattern with tumor necrosis. The tumor shows eosinophilic cytoplasm, nuclear hyperchromasia, pleomoephism, loss of polarity, prominent nuleoli and mitoses.
      • Immunohistochemical stain reveals p16(patchy positive), p53(wild type), CK7(+), CK20(-) and vimentin(+).
    • 2021-12-31 Gynecologic ultrasonography
      • Uterine myoma
      • Uterine mass: 27x23mm, no blood flow
    • 2021-11-09 SONO - abdomen
      • Bil. liver cysts (up to 1.0cm).
    • 2021-11-09 SONO - breast
      • Right fibroadenomas
      • s/p right breast operation
      • benign
    • 2021-05-07 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20200316, no prominent change is noted in the lesions in the lower L-spines. Degenerative spine diseases may show such a picture.
      • Increased radiotracer uptake in maxilla and mandible, Dental lesions may show this picture.
      • Probably degenerative change in bilateral shoulders, sternoclavicular junctions, sacroiliac joints, knees, ankles and both feet.
      • No prominent bone abnormality was noted elsewhere.
    • 2021-03-16 Mammography
      • Post-op with breast tissue reduction in right breast.
      • Benign calcifications in bilateral breasts.
    • 2021-03-16 SONO - breast
      • Operation scar at right UOQ breast.
      • Probably right breast fibroadenomas, stationary.
    • 2021-03-02 Gynecologic ultrasonography
      • uterine myoma
    • 2020-12-08 SONO - breast
      • Operation scar at right UOQ breast.
      • Probably right breast fibroadenomas.
    • 2020-03-18 SONO - breast
      • Breast tissue reduction in right breast, could be due to post-op change.
      • Benign calcifications in bilateral breasts.
    • 2020-03-16 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20190114, the previously noted faint hot spots in bilateral rib cages had disappeared, indicating benign in nature.
      • Mildly and non-focally increased radiotracer uptake in lower L-spine, degenerative spine diseases may show such a picture.
      • Increased radiotracer uptake in maxilla and mandible, suggesting dental lesions.
      • Probably degenerative change in shoulders, sternoclavicular junctions, sacroiliac joints, knees, and ankles.
      • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
    • 2019-02-12 Whole body PET scan
      • Mild glucose hypermetabolism in the right breast. The nature is to be determined (post-operative inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in bilateral shoulder joints, compatible with benign joint lesion such as arthritis.
      • Mildly increased FDG accumulation in the colon. Physiologic FDG accumulation is more likely.
    • 2019-01-22 Pathology Level VI
      • Pathologic diagnosis
        • Breast, right, partial mastectomy — Invasive carcinoma of no special type (90%) with focal mucinous carcinoma (10%)
        • Resection margin: Free of carcinoma
        • Lymph node, right axillary sentinel, lymphadenecomy — Metastatic carcinoma (1/1)
        • Pathology stage: pT2N1a(sn)(cMx); Anatomic stage IIB, Prognostic stage IB
      • Microscopic examination
        • Histologic grade (Nottingham histologic score): Grade I (score= 5)
        • Tumor necrosis: Present
        • Nodal status (Sentinel): Positive (1/1)
        • Treatment Effect: No presurgical neoadjuvant therapy received
        • Lymphovascular invasion: Absent
        • Perineural invasion: Absent
      • Immunohistochemical study (S2019-00163)
        • ER (Ab): Positive (90%)
        • PR (Ab): Positive (90%)
        • HER-2/Neu (Ab): Negative (score=0)
        • Ki-67: <5%
        • p53: <2%.
    • 2019-01-04 Surgical pathology Level IV
      • Breast, right, 10 o’clock/3cm, SONO guided core biopsy — Invasive carcinoma.
      • IHC: ER (+, 90%), PR: (+, 90%), Her2/neu: negative (score=0); Ki-67: <5%, p53: <2%.
    • 2019-01-03 SONO - breast
      • Highly suspicious of malignancy, with sonographic negative axillary LNs, suspected carcinoma, cT2N0.
      • BI-RADS: 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken.
  • consultation
    • 2022-02-26 Urology
      • Q
        • For on D-J catheterization.
        • This 51-year-old female with endometrial cancer  was admitted for staging surgery at 20220207. 
        • We need your evaluation of her condition for inserted D-J catheterization. Thanks for your help!
      • A
        • MRI showed lymph node and mild dialation of right renal pelvis.
        • We will stand by for this procedure
  • surgical operation
    • 2022-02-07 Endometrial cancer - Staging surgery (ATH + BSO + lymph node dissection + infracolic omentectomy)        
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, peritoneum due to tumor mass accupied .
      • Adnexa:
        • LOV: 3x2x2cm, capsule intact, smooth surface.
        • ROV: 3x3x3cm, capsule intact, smooth surface.
        • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
    • 2022-01-06 Transcervical resection polypectomy      
      • One endometrial polyp from low segemtn of uterus, with stalk from 5o’clock of direction
    • 2019-01-21 right breast cancer - BCT + SLND
  • radiotherapy
    • 2022-03-09 ~ 2022-04-28 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
    • 2019-08-27 ~ 2019-10-17 - 5000cGy/25 fractions of the right breast to right SCF, and 6000cGy/30 fractions of the right breast tumor bed (scar) area.
  • chemoimmunotherapy
    • 2022-08-15 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-07-25 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-07-04 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-06-08 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 450mg 2hr
    • 2022-04-20 - paclitaxel 175mg/m2 360mg 3hr + carboplatin AUC 5 450mg 2hr
    • 2022-03-18 - paclitaxel 175mg/m2 330mg 3hr + carboplatin AUC 5 450mg 2hr
    • 2021-03-02 ~ 2021-05-18 - Medrone (medroxyprogesterone acetate) 5mg/tab 1# QD PO
    • 2019-08-13 ~ undergoing - Femara (letrozole) 2.5mg/tab 1# QD PO (Letrozole, or CGS 20267, is an oral non-steroidal type II aromatase inhibitor first described in the literature in 1990. It is a third generation aromatase inhibitor like exemestane and anastrozole, meaning it does not significantly affect cortisol, aldosterone, and thyroxine)
    • 2019-02-25 ~ 2019-08-05 - (pegylated liposomal) doxorubicin + cyclophosphamide

[note]

  • Taxane derivatives: When administered as sequential infusions, taxane derivatives (docetaxel, paclitaxel) should be administered before the platinum derivatives (carboplatin, cisplatin) to limit myelosuppression and to enhance efficacy.

==========

2022-07-26

  • RBCs were 2.75106/uL and HGBs were 7.8g/dL on 2022-07-25. 2U of LPRBC (Leukocyte-poor RBC) had been transfused on the night of 2022-07-25.

2022-06-09

  • In this patient, endometrial cancer has been diagnosed following ATH + BSO + lymph node dissection + infracolic omentectomy on 2022-02-07. The patient is receiving treatment with paclitaxel + carboplatin from 2022-03-18. Before that, the right breast invasive carcinoma was treated with partial mastectomy on 2019-01-21, followed by doxorubicin + cyclophosphamide from 2019-02-25 to 2019-08-05, followed by letrozole from 2019-08-13.
  • Lab data reported on 2022-06-08 indicated that liver and kidney functions, serum electrolytes, and blood cell counts were grossly normal.

2022-04-21

  • This patient has been diagnosed with endometrial cancer s/p ATH + BSO + lymph node dissection + infracolic omentectomy on 2022-02-07 and is being treated with paclitaxel + carboplatin since 2022-03-18. Prior to that, right breast invasive carcinoma was treated with partial mastectomy on 2019-01-21, followed by doxorubicin + cyclophosphamide from 2019-02-25 to 2019-08-05, then letrozole since 2019-08-13.
  • Lab data reported on 2022-04-20 showed that liver and kidney function, serum electrolytes, and blood cell counts were grossly normal.

700341500

220722

{colon cancer with liver mets}

[objective]

  • lab data
    • Creatinine
      • 2022-07-21 1.62 mg/dL
      • 2022-07-06 1.59 mg/dL
      • 2022-06-12 1.85 mg/dL
      • 2022-05-27 1.84 mg/dL
      • 2022-04-30 1.67 mg/dL
      • 2022-04-22 1.55 mg/dL
      • 2022-03-30 1.66 mg/dL
      • 2022-03-17 1.46 mg/dL
      • 2022-03-01 1.81 mg/dL
      • 2022-02-25 1.90 mg/dL
      • 2022-02-22 1.68 mg/dL
      • 2022-02-10 1.25 mg/dL
      • 2022-02-07 1.30 mg/dL
      • 2022-01-20 1.31 mg/dL
      • 2022-01-15 1.55 mg/dL
      • 2022-01-06 1.51 mg/dL
      • 2021-12-20 1.35 mg/dL
  • exam finding
    • 2022-06-29 SONO - abdomen
      • Chronic liver parenchymal disease
      • Hepatic tumors C/W metastatic liver tumors
    • 2022-05-27 CXR
      • S/P port-A implantation.
      • Borderline cardiomegaly
      • Bamboo spine is noted that is c/w ankylosing spondylitis.
    • 2022-05-02 CT - abdomen, pelvis
      • Findings
        • Several low density lesions are found at both lobes of liver up to 4.35cm in largest dimension. In comparison with CT dated on 2021-12-21, these lesions decreased in size
        • Filling defect at infrarenal aorta is found. r/o thrombus formnation. The lesion could also be found at previous CT.
        • Enlarged left adrenal gland is found. Metastasis is considered. In regression.
        • There is no evidence of paraarotic LAPs.
        • Mild thrinkage of the sigmoid colon mass is found.
        • The urinary bladder is well distended without soft tissue lesion.
        • No definite inguinal or pelvic sidewall LAP
        • Ankylosis of the thoracolumbar spine is found.
      • Imp:
        • Sigmoid colon cancer with liver and left adrenal mets, all of the tumor activity regressed and decreased in size.
        • Infra-renal aortic thrombus formation with stable size. suspected chronic thrombus formation. Suggest further treatment.
    • 2022-02-23 ECG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Anteroseptal infarct, age undetermined
      • T wave abnormality, consider inferolateral ischemia
      • Abnormal ECG
    • 2022-02-23 2D transthoracic echocardiography
      • Dilated LA and LV
      • Septal hypertrophy
      • Poor LV systolic function
      • Adequate RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR and TR
      • Hypokinesis of anteroseptal, anterior, apical and inferioposterior wall
    • 2022-02-22 ECG
      • Sinus tachycardia
      • Minimal voltage criteria for LVH, may be normal variant
      • Anterior infarct, age undetermined
      • T wave abnormality, consider lateral ischemia
    • 2022-02-22 Cardiac catheterization
      • In conclusion: Coronary artery disease, 1VD, m-LAD; Syntax score 9 s/p POBA and stenting with Boston SYNERGY Drug-eluting stent. 4.0 X 48 mm for proximal LAD to middle LAD.
      • Recommendation: Patient had take PPI and gastritis history, shift ticagrelor to clopiodgrel later.
    • 2021-12-23 Patho - colorectal polyp
      • A. Colon, transverse colon, s/p hot snare polypectomy (E) - Tubulovillous adenoma with low grade dysplasia.
      • B. Colon, 10cm to 20cm AAV, s/p biopsy (F) - Adenocarcinoma.
        • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    • 2021-12-23 Colonoscopy
      • Colon polyp, transverse colon, s/p EMR and clipping.
      • Highly suspected colon cancer, 1-cm to 20cm AAV, s/p biopsy.
      • Colon polyps, s/p polypectomy and biopsy, at least four residue polyps not polypectomized.
    • 2021-12-21 CT - abdomen - liver, spleen, biliary duct, pancreas
      • Suspected rectosigmoid cancer with liver and left adrenal metastasis.
      • Small right lung nodule, suspected lung metastasis.
      • Right renal stones. Left middle ureteral stone with hydronephrosis.
    • 2021-12-17 Abdominal ultrasound
      • Parenchymal liver disease, suspected liver cirrhosis.
      • Hepatic tumors, HCC with portal vein invasion or metastatic tumor with vessel compression were suspected.
      • Left hydronephrosis, mild
      • Splenomegaly
  • consultation
    • 2022-02-24 Rehabilitation
      • A
        • Assessment
          • ST elevation myocardial infarction, 1-vessel coronary artery disease, s/p balloon angioplasty and drug eluting stenting on 2022/02/22 -colon cancer
        • Plan
          • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs
          • Goal: recondition, improve endurance and muscle strength
          • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
    • 2022-02-22 Cardiology
      • This 69 y/o male is a case of colon CA. He admitted due to chest pain. EKG ST elevation, anterior wall
      • bed side 2D anteroseptal, anterior and apex hypokinesia
      • Past history:
        • colon CA
      • impression
        • STEMI, onset <12 hours
      • Suggestion
        • Dual anti-PLT therapy (aspirin 3# po STAT and brilinta 2# po STAT; then spirin 1# po QD and brilinta 1# po QD) and anticoagulation (such as heparin 4000U stat)
        • We explain the indication of primary percutaneous coronary intervention in order to save life, but also potential risks of PCI including stroke around 1/1000.
        • Arrange admission to MICU
    • 2021-12-24 Colorectal Surgery
      • Q
        • for management of favor colon cancer with liver, lung and adrenal mets
        • This 68 y/o male due to Liver tumor, HCC with right portal vein invasion or metastatic tumor with vessel compression were suspected. He was admitted to our GI ward for management and further survey.
        • After admission, Colonscopy was done that showed Highly suspected colon cancer, 10cm to 20cm AAV, s/p biopsy.
        • Now, we will be pending pathology and need your management of favor colon cancer with liver, lung and adrenal mets. Thanks a lot!!!
      • A
        • I’ve visited this case. The patient was a case of colon cancer with multiple liver, lung, adrenal metastasis
        • O
          • Oral intake : well
          • Appetite: good
          • Stool passage: Normal
          • No obstruction sign
        • IMP:Colon cancer with multiple metastasis
        • Suggestion:
          • Consult Oncology for palliative chemotherapy + target therapy
          • Surgery will be reserved for obstruction for the patient
          • Thanks for your consultation
    • 2021-12-23 Urology
      • Q
        • Now, abdominal CT was done that showed Left middle ureteral stone with mild hydronephrosis.
      • A
        • Due to stone impaction with renal insufficiency, URSL with short term DBJ insertion (7 days) is indicated.
        • Treating stone may yield better renal function for chemotherapy in the future.
        • I will discuss with him after colonscopy
        • Adrenal tumor was seen. Metastasis is suspected.
        • Thanks for your consultation
  • chemotherapy
    • 2022-01-20 ~ undergoing - bevacizumab 5mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 2800mg/m2 46hr (FOLFIRI plus bevacizumab)
    • 2022-01-20 - bevacizumab 5mg/kg 90min + irinotecan 160mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 2800mg/m2 46hr
    • 2022-01-06 - irinotecan 160mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 2800mg/m2 46hr

==========

2022-07-22

  • 2022-07-21 Creatinine 1.62 mg/dL, 171 cm, 74 kg, 69 years old => CrCl 45 mL/min, eGFR 49 mL/min. There is no need to adjust doses in the active prescription.

2022-07-07

  • Following the administration of FOLFIRI plus bevacizumab since 2022-01-20, CT scan on 2022-05-02 revealed that all tumor activity had regressed and decreased in size.
  • Under daily taking of aspirin and clopidogrel, an infra-renal aortic thrombus of stable size was also demonstrated on 2022-05-02 CT.
  • TPR, BP signs during this hospitalizaion and lab data on 2022-07-06 were grossly normal except for creatinine 1.59 mg/dL. Chemotherapy should be able to proceed as scheduled.

2022-03-18

701084563

220722

{Small Lymphocytic Lymphoma}

[objective]

  • lab data
    • BUN
      • 2022-07-21 BUN 60 mg/dL
      • 2022-07-13 BUN 41 mg/dL
      • 2022-07-08 BUN 56 mg/dL
      • 2022-07-06 BUN 56 mg/dL
      • 2022-07-04 BUN 52 mg/dL
      • 2022-06-27 BUN 32 mg/dL
      • 2022-06-22 BUN 24 mg/dL
      • 2022-06-10 BUN 19 mg/dL
      • 2022-06-01 BUN 18 mg/dL
    • Procalcitonin (PCT)
      • 2022-07-21 Procalcitonin(PCT) 4.53 ng/mL
      • 2022-07-13 Procalcitonin(PCT) 0.43 ng/mL
      • 2022-06-23 Procalcitonin(PCT) 0.82 ng/mL
      • 2022-06-01 Procalcitonin(PCT) 0.40 ng/mL
      • 2022-04-21 Procalcitonin(PCT) 1.76 ng/mL
    • 2022-03-22 BCR-abl mutation undetectable
    • 2022-03-16 bone marrow
      • FLT3-D835 mutation undetectable
      • FLT3/ITD mutation undetectable
      • NPM1 mutation undetectable
  • exam finding
    • 2022-07-20 CXR
      • Ground glass opacities in bil. lungs.
    • 2022-07-14 Patho - paranasal biopsy
      • Nasal septum, left, biopsy — Necrotic tissues with candidiasis
      • Microscopically, it shows necrotic debris with granulation tissue, leukocytic infiltrate and presence of bacterial clumps and fungal hyphae. No viable tissue is seen.
    • 2022-07-14 Nasopharyngoscopy
      • Nasal lesions
    • 2022-07-13 Nasopharyngoscopy
      • Ulceration at L buccal, L retromolar trigone, L soft palate, blood clot with whitish
    • 2022-07-12 MRI - nasopharynx
      • Enlarged left posterior cervical and bil. supraclavicular LNs as indicated on axial fat sat T2WI when compared with 2021/09/08, 2021/03/23 MRI studies.
    • 2022-07-08, -07-04 CXR
      • Nodular opacities projecting in both lung are suspected. Please correlate with CT.
      • Right pleura effusion is noted.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-06-27 2D transthoracic echocardiography
        1. Dilated LA and LV; severely abnormal LV systolic function with global hypokinesia
        1. Minimal pericardiac effusion
        1. Moderate to severe MR, mild to moderate TR
        1. LV diastolic dysfunction, Gr 1
        1. Impaired RV systolic function
    • 2022-06-23 ECG
      • Sinus tachycardia
      • Nonspecific T wave abnormality
      • Poor wave progression V1~3
      • Abnormal ECG
    • 2022-03-08 Patho - lymph node region resection
      • Lymph node, right neck, excision - Small lymphocytic lymphoma
      • IHC: CD20(+), CD23(+), CD3(-), CD5(+) and CD10(-).
      • According to above histopathologic findings and past history, it is consistent with small lymphocytic lymphoma.
    • 2022-03-04 Whole body PET scan
      • Glucose hypermetabolism in bilateral axillary lymph nodes, bilateral supra and infraclavicular lymph nodes, bilateral neck lymph nodes and abdominal lymph nodes, suggesting recurrent lymphoma involving multiple lymph node regions on the both sides of the diaphragm (stage III).
      • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulation is more likely.
    • 2022-03-03 Patho - bone marrow biopsy
      • Bone marrow, iliac bone, biopsy - Small lymphocytic lymphoma / chronic lymphocytic leukemia
      • IHC: CD20(+), CD3(-), CD23(+), CD34(-), CD117(-), CD61 showed adequate megakaryocyte with focal mononucleation and hyposegmentation, MPO and CD71 showed marked hypoplasia of both myeloid and erythroid series.
    • 2021-12-21 SONO - abdomen
      • Two gallbladder polyp or sludge (2.2 mm).
      • A renal cyst measuring 1 cm in left lower pole is noted.
    • 2021-09-28 MRI - larynx
      • Small residual bil. supraclavicular LNs, seems stationary.
      • Markedly regression in other neck LNs found, stationary.
    • 2021-07-06 SONO - abdomen
      • Two gallbladder polyp or sludge (< 2 mm).
      • A renal cyst measuring 0.89 cm in left lower pole is noted.
    • 2021-03-23 MRI - larynx
      • Small residual bil. supraclavicular LNs, stationary.
      • Markedly regression in other neck LNs found, stationary.
    • 2020-12-29 SONO - abdomen
      • A gallbladder polyp 2.5 mm.
      • A renal cyst measuring 0.93 cm in left lower pole is noted.
    • 2020-10-06 MRI - larynx
      • Small residual bil. supraclavicular LNs.
      • Markedly regression in other neck found.
      • Chronic bil. paranasal sinusitis.
    • 2020-05-11 MRI - brain
      • Subacute ICH at left anterior frontal base. No evidence of brain metastasis.
    • 2020-05-06 CT -brain
      • localized SAH in the bilateral inferior frontal regions.
    • 2020-04-16 Patho - bone marrow biopsy
      • Bone marrow, biopsy - Compatible with B-cell lymphocytosis
      • B-cell proliferation in focal area, arranged in interstitial pattern, which immunohistochemistry shows CD3 and CD5: similar pattern, CD23: almost (-), CD20(+), Cyclin-D1(-), MPO(+) for myeloid series, CD71(+) for erythroid series, CD61(+) for megakaryocytes and CD117(+) for blast.. According to all above histopathologic findings, it is compatible with B-cell lymphocytosis due to lack aberrant expression.
    • 2020-04-08 Whole body PET scan
      • Glucose hypermetabolism in bilateral axillary lymph nodes, supraclavicular lymph nodes, and cervical lymph nodes, suggesting lymphoma with tumor recurrence in multiple lymph node regions.
      • Glucose hypermetabolism in the spleen and bilateral inguinal lymph nodes, the nature is to be determined. Please correlate with clinical findings and keep follow up to exclude the possibility of tumor recurrence in these regions.
      • B-cell lymphoma s/p treatment with tumor recurrence, rc-stage II, at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2020-03-27 Patho - lymphnode biopsy
      • Lymph node, right neck, excision - Small lymphocytic lymphoma
      • IHC: CD20(+), CD23(+, focal), CD3(-), CD5(+, focal), Bcl-2(+).
      • According to above histopathologic findings and past history, it is consistent with small lymphocytic lymphoma.
      • Reference: S2014-05750 Lymph node, neck, excisional biopsy - Chronic lymphocytic leukaemia / small lymphocytic lymphoma
    • 2020-03-19 MRI - larynx
      • lymphoma with extensive neck lymphadenopathy.
  • consultation
    • 2022-07-13 ENT
      • Q
        • For chronic rhinosinusitis
        • This 64-year-old female has the medical history of congestive heart failure, and chronic lymphocytic leukemia, small lymphocytic lymphoma (CLL/SLL) diagnosed in 2014/04.
        • She was admitted for progressively enlarging bilateral axillary lymph node. She was orginally under Venetoclax treatment. However, the treatment was paused recently due to low WBC count.
        • Her current conditions are stable. However, she complained of headache (forehead headache), facial apin and facial fullness in these days. We have arranged nasopharynx MRI for her. Yet, no obvious discharge or foreign body was seen over bilateral maxillary sinuses. We need your help for further survey for chronic sinusitis! Thank you!
      • A
        • S
          • Facial pain, oral ulcer VAS 2~3 for 10+ days.
          • Previous epistaxis (+)
          • Hx of CLL/SLL
        • PE:
          • Nose: ulceration at L nasal septum
          • Scope: Ulceration at L buccal, L retromolar trigone and L soft palate, blood clot with whitish lesion on bil nasal septum and middle turbinate
        • Imp:
            1. Impending destruction of nasal septum, suspect CLL/SLL related
            1. Suspect fungal infection of nasal cavity, or previous epistaxis related
            1. Stomatitis, related to previous chemotherapy
        • Plan:
            1. ENT OPD f/u nasal condition for further local tx
            1. L nasal septal ulcerative tissue sent for pathology
            1. Oralog for oral ulcer
    • 2022-06-23 Cardiology
      • Q
        • This is a 64-year-old female with history of chronic lymphocytic leukemia, small lymphocytic lymphoma (CLL/SLL) diagnosed in 2014/04, Ann Arbor stage IV (BM involved), s/p R-CHOP x 2 (ceased in 2014-06, due to rapid progression), Bendamustin/Rituximab (BR) x 7 (finished in 2014-12, with CR).
        • Recurrent CLL/SLL at bil. axillary LNs, supraclavicular LNs, and cervical LNs was found, s/p BR Q3W x 5 (finished in Aug 2020-08).
        • Third time recurrent CLL/SLL confirmed in 2022/03 involving multiple lymph node regions at diaphragm stage III, with right neck lymph nodes biopsy confirmed SLL.
        • Thus, she underwent another session of chemotherapy with BR since 2022/03/21, C2 on 2022/04/25, C3 on 2022/06/01. After last cycle, the patient was noted to be pancytopenic with 11K of PLT, Hb 7.3, WBC 530 on the first revisit of hematology OPD. Blood transfusion with LRP 2U + LPRBC 1U were given and GCSF x 5 days was administered. The patient was then sent home with relatively stable condition. The patient also suffered from hemorrhoid, and went to LMD with medication use currently.
        • This time, the patient came to Dr. Wan’s OPD for help on 2022-06-22 with complaint of rapid progression of bilateral axillary lymph node swelling with heat and mild pain for 10 days. Mild dyspnea was also noted. The patient was thus referred to ER for emergent care. At ER, vital signs showed BT 37.6, BP 109/63mmHg; HR:134BPM; RR:20, with 94% spO2 under room air. Lab study found pancytopenia with Hb 5.9, PLT 6K WBC 6.86K with ANC 274. Emergent blood transfusion with LPRBC 4U + LRP 1U was given with dexamethasone and GCSF ST. The patient was then admitted to our ward for further evaluation and management.
        • After admission, neutropenic fever was noted. Abx of tapimycin was given. Due to CLL, rituximab, endoxan and prednisolon was given. High fever was noted in this morning with HR up to 150bpm. Bedside EKG showed sinus tachycardia without ST-T change. Troponin I was 1192.9 pg/ml. She only complained about mild dyspnea with fever and chillness. There was no typical chest pain. Follow-up EKG and troponin still showed sinus tachy with troponin upto 1495.9 pg/ml. We need your expertise for further evaluation and managment. Thanks!
        • Dx: CLL, neutropenic fever, UTI
        • For elevated troponin I from 1192.9 -> 1495.9
      • Q
        • S
          • This 64 y/o female patient is a case of CLL s/p C/T with pancytopenia. She was admitted for further treatment. PRBC 4U and PLT 3U were administered in the past 1 day. She complained of marked dyspnea today. Othropnea was also noticed. Elevated cardiac markers were detcted. Now we are consulted.
        • O
          • BP:119/76 mHg; HR:124
          • Consciousness: clear and acute ill looking
          • Chest: bilateral basal rales heard
          • Heart: RHB with tachycardia, grade 1~2/6 SM at LLSB
          • 20220623 EKG: sinus tachycardia with HR 135 BPM, nonspecific T wave abnormality
          • 20220622 sugar: 115, Cr: 0.51, AST/ALT: 26/42, CRP: 18.44, NTproBNP: 4105, hsTroponi-I: 1192 -> 1495
          • Hb:5.9 -> 8.4 -> 9.9
        • Impression:
            1. CLL s/p C/T with pancytopenia
            1. Acute pulmonary edema, suspected myocardial failure or fluid overload due to blood transfusion and large IV fluid administeration, or combination of these factors
            1. Suspected chemotherapy related cardiac toxicity with myocardial failure
        • Suggestion:
            1. Acute pulmaonry edema is prefered according to the physical examination. Please give IV lasix 1amp stat and 1amp Q12H. Arrange CXR stat.
            1. The patient has no past histyory of HTN, DM or smoking. She also denied past history of effort related angina. Acute MI with elevated cardiac markers is not likely. The elvated hsTroponin-I was possible due to demand ischemia (because of severe anemia), or myocardial failure due to chemotherapy. Please arrange echocardiography to evaluate LV function.
    • 2022-06-23 Family Medicine
      • Q
        • Due to progressed CLL, DNR was agreed by patient and family. We need your expertise for share care. Thanks!
      • A
        • 64 y/o lady CLL
        • DNR +
        • Our share care would follow up.
        • Thanks for consultation.
    • 2022-03-03 General and Gastrointestinal Surgery
      • Q
        • This time, she has nasal and gums ulcer with swelling at first and then multiple LNs enlarged over bilateral neck, supraclavicle and axillary in Chinese New Year and fatigue in recently days. She denied night sweat or BW loss. Due to leukocytosis and higher LDH, so she was admitted for management.
        • Due to swollen lymph nodes at right neck, so we need your help for lymphadenectomy and biopsy, thanks a lot!!
      • A
        • S: R’t neck lymph node excision is consulted.
        • O: vital signs: stable, no fever
          • PE: multiple enlarged lymph nodes over bilateral lateral neck
          • lab data: see chart
        • A: Chronic lymphocytic leukaemia / small lymphocytic lymphoma, suspect recurrence
        • P: I will right neck LN biopsy on 3/8
    • 2020-12-12 Neurology
      • Q
        • Patient’s mouth twisted to the right
      • A
        • O
          • NE E4V5M6
          • CNs: left peripheral facial palsy
          • MP: full
          • sensation: intact
          • FNF: no dysmetria
          • gait: steady
          • brain CT: no ICH
        • impression: left bell palsy
        • plan:
          • give prednisolone 1mg/kg QD, famotidine 1# QD for 4 days (till W2 OPD)
          • give kentamin 1# BID, and duratea ointment
          • neurology OPD follow-up on W2
    • 2020-05-08 ENT
      • Q
        • for severe dizziness & sudden onest of syncope on 5/6 night & 5/7 night about 10-20 sec
        • This 61-year-old female, a patinet of small B cell lymphoma S/P C/T. She was admitted for C/T with BR on 5/5-5/6 20. Sudden onest of vomiting & dizziness was developed on 5/6 20 afternoon at 18:15 pm. The brain CT (5/6 20) showed localized SAH in the bilateral inferior frontal regions. We need expertise to evaluate her condition thanks!
      • A
        • S: vertigo when postion change
        • O: dix-hallpike: left rotational nystagmus
        • A: suspected left BPPV
        • P:
          • left Epley (done)
          • symtpomatic treatment
          • ENT OPD f/u
          • please survey other cause of syncope
    • 2020-05-07 Neurosurgery
      • Q
        • For localized SAH in the bilateral inferior frontal regions evaluation
        • This 61-year-old female, a patinet of small B cell lymphoma S/P C/T. She was admitted for C/T with BR on 5/5-5/6 20. Sudden onest of vomiting & dizziness was developed on 5/6 20 afternoon at 18:15 pm. The brain CT (5/6 20) showed localized SAH in the bilateral inferior frontal regions.We need expertise to evaluate her condition. thanks!
      • A
        • S/O
          • 61 y/o female
          • Head trauma owing to an accidental fall last night. No loss of consciousness.
          • c/o headache and dizziness.
          • Consciousness clear.
          • Head CT scan: minimal anterior interhemispheric SAH.
        • A/P
          • Rx:
          • No neurosurgery is indicated.
          • Neuro monitoring and treatment for about 3 days.
          • Symptomatic treatment.
  • surgical operation
    • 2022-03-08 Excision of r’t neck tumor
    • 2020-03-27 Excisional biopsy, right neck enlarged LAP
  • chemoimmunotherapy
    • unknown - venetoclax
    • 2022-06-23 rituximab 375 mg/m2 10hr
    • 2022-06-02 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
    • 2022-04-25 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
    • 2022-03-21 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
    • 2022-03-18 ~ 2022-03-23 - hydroxyurea 500 mg BID
    • 2022-03-11 ~ 2022-03-18 - cyclophosphamide 50 mg BID
    • 2020-08-03 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
    • 2020-07-07 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
    • 2020-06-16 rituximab 375 mg/m2 6hr D1 + bendamustine 100 mg/m2 90 min D1-2
    • 2020-05-26 rituximab 375 mg/m2 10hr D1 + bendamustine 70 mg/m2 90 min D1-2
    • 2020-05-05 rituximab 375 mg/m2 10hr D1 + bendamustine 70 mg/m2 90 min D1-2
    • 2014-07 ~ -12 - rituximab + bendamustin (CR)
    • 2014-05 ~ -06 - R-CHOP, ceased due to rapid progression

==========

2022-07-22

  • According to UpToDate, cardiovascular adverse reactions of rituximab are Cardiac disorder (5% to 29%), flushing (5% to 14%), hypertension (6% to 12%), peripheral edema (8% to 16%), and a cardiovascular adverse reaction of bendamustine is Peripheral edema (13%).
  • It is recommended to have cardiac ultrasound routinely when the patient is undergoing treatment since she has a history of heart failure, abnormal ECG, and edema. The most recent 2D transthoracic echocardiography was done on 2022-06-27.

2022-07-21

  • Tapimycin (piperacillin + tazobactam) is adequate for ground glass opacities in bil. lungs (2022-07-20 CXR). No dose adjustment is needed based on 2022-07-21 lab data.

2022-03-22

  • For this patient with recurrent SLL, the r’t neck tumor was excised on 2022-03-08.
  • The patient is receiving bendamustine and rituximab, the same regimen used from May to August of 2020.
  • There were no detectable mutations in any of the following genes: BCR-abl (2022-03-22), FLT3-D835, FLT3/ITD, and NPM1 (2022-03-16).
  • There is no del(17p), TP53 mutation status, CpG-stimulated karyotype or IGHV mutation status found in lab data.

700077356

220720

{left pyriform sinus cancer, cT2N2bMx, stage IVA, brain mets}

  • exam finding
    • 2022-07-13 Electroencephalography, EEG
      • Findings
          1. the posterior background activities are at 10 Hz, symmetric and responsive to eye opening
          1. photic stimulation showed symmetric photo-driving response
          1. hyperventilation study was not done
      • EEG classification: normal
      • Interpretation: normal
    • 2022-07-12 Pure-tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 29 dB HL; LE 29 dB HL.
      • R’t normal to moderate SNHL.
      • L’t normal to moderately severe SNHL.
    • 2022-06-23 Patho - larynx biopsy
      • Left pyriform sinus medial wall, LMS for tumor mapping — Moderately differentiated squamous cell carcinoma
      • IHC stain — p16(-)
    • 2022-06-23 Whole body PET scan
        1. Glucose hypermetabolism in the left pyriform sinus, compatible with primary hypopharyngeal malignancy. Please correlate with other clinical findings for further evaluation.
        1. Glucose hypermetabolism in multiple left neck level IV and Vb lymph nodes, suggesting multiple ipsilateral lymph node metastases.
        1. Increased FDG accumulation/uptake in bilateral masseter muslces, both kidneys, bilateral ureters and colon. Physiological FDG accumulaion/uptake is more likely.
    • 2022-06-22 Frozen section
      • initial diagnosis: Pyriform sinus, left, frozen section — squamous cell carcinoma
    • 2022-06-22 SONO - abdomen
      • Diagnosis
        • Cirrhosis of liver with splenomegaly
        • Liver cyst
        • Portal hypertension
        • Chronic calcified pancreatitis with pancreatic duct dilatation
        • Subpleural consolidation of LLL with minimal pleural effusion
      • Suggestion
        • OPD follow-up
    • 2022-06-22 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Hypopharyneal tumor
        • Suspected Barett’s esophagus, C3M5
        • Reflux esophagitis LA grade A
        • Cervical inlet patches
        • Superficial gastritis
        • Suspected cascade stomach
      • Suggestion
        • Biopsy was NOT done due to anticoagulation.
    • 2022-06-16 Nasopharyngoscopy
      • Findings
        • bi nasal cavity and middle meatus clear; smooth nasopharynx; normal vocal function: granular tumor at left
        • pyriform sinus and left AE fold and left arytenoid
      • Summary:
        • left pyriform sinus and left supraglottis tumor, favor malignancy
    • 2022-05-30 MRI - nasopharynx
      • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage): T2N2bMx, stage IVA
    • 2021-03-11 MRI - nasopharynx
      • He had buccal cancer of left side 2013-10. abnormal mass-like fibrotic soft tissue overgrowth with ugly surface is noted at the left buccal mucosa.
      • IMP:
          1. focal mucosal thickening in the left upper and posterior buccogingival mucosa. Nature?
          1. prominent right oropharyngeal tonsil. Nature?
    • 2019-03-01 MRI - nasopharynx
      • Indication:
        • S: He is an oral cancer patient and received operations. He has poor liver function and lower bleeding control at this moment (waiting for liver transplantation).
        • O: Fungus infection at the left buccal mucosa is noted. leukoplakia on the left tongue border near #36 with mild ulceration is noted. surgical defect at the left buccal mucosa and tuberosity with fibrotic soft tissue overgrowth with ugly surface are present
        • A:
            1. SCC of left buccal mucosa (pT1N0M0) s∕p OP (2013-10)
            1. Trismus and fungus infection
        • P:
            1. BUN: normal
            1. arrange MRI with contrast to evaluate undermining tumor status
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
          1. Post operation change at left buccal region with abscence of subamandibular gland. No focal mass or nodule.
          1. Post left neck lymph nodes dissection .
          1. No evident abnormal enlarged lymph node in the visible neck.
          1. No abnormal enhancement in the tongue.
          1. A right maxillary retension cyst up to 1.7cm.
          1. No abnormal signal intensity of the mandible.
      • IMP:
        • post op change at left buccal region.
        • no recurrent tumor.
  • consultation
    • 2022-07-12 Neurology
      • Q
        • This 46-year-old man patient is a case of Left piryform sinus cancer, cT2N2bM0, stage IVA. He was admited for prepare chemotherapy. Alcoholic cirrhosis of liver without ascites, child A with Encephalopathy on 2022/07/11 after admitted. He was to Taipei Mackay Hospital with brain CT on 2022/07/11 showed no brain metastasis.
        • Now, for evaluate Alcoholic cirrhosis of liver without ascites, child A with Encephalopathy examination and therapy. Thank you.
      • A
        • O
          • seizure as hypnopompic twitching of limbs
          • similar attack as alcohol withdrawal seizure before
          • NE: aware, fluent speech, normal cranial nerves, no obvious focal weakness
        • Impression:
            1. sleep related seizure or sleep related movement disorders
        • Suggest:
            1. EEG might be arranged
            1. Rivotril might be added as (0.5mg) 1-2# HS
            1. I would like to follow up this patient.
    • 2022-06-24 Oral and Maxillofacial Surgery
      • Q
        • This 46-year-old man has history of type 2 diabetes mellitus with medication control and alcoholic cirrhosis of liver without ascites, child A wait for liver transplantation. He had personal history of smoking, betel nut chewing and drink wine for over 15 years, quitted betel nut and drink 8 years ago. He had left buccal cancer, pT1N0M0, stage I, status post operation on 2013/10/07 at our hospital by OS Dr.Xia. He regular follow at Dr.Xia OPD.
        • This time, left pyriform sinus cancer, cT2N2bMx, stage IVA was diagnosed, induction chemotherapy was indicated. We request your consultation for dental evaluation.
      • A
        • Currently, no emergency treatment or prophylactic dental extraction is needed. Please arrange routine dental follow up after patient’s finished the cancer treatment .
    • 2022-06-23 Hemato-Oncology
      • Q
        • For induction chemotherapy for left pyriform sinus cancer, cT2N2bMx, stage IVA evaluation (Hx: DM, liver cirrhosis, child A)
        • Neck MRI followed on 2022/05/30 which revealed left pyriform sinus cancer, cT2N2bMx, stage IVA. He then was transferred to our ENT OPD. At OPD, scope showed granular tumor at left pyriform sinus and left AE fold. Several enlarged LN at left neck level IV and Vb, the largest one around 3cm at left Vb. Admission for laryngomicrosurgery biopsy and further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of left pyriform sinus cancer, the patient was admitted.
      • A
        • Impression:
            1. left pyriform sinus cancer, SCC, cT2N2bMx, stage IVA
            1. Diabetes mellitus
            1. Liver cirrhosis, child A
        • Suggestion:
            1. Induction chemotherapy is indicated. Thanks for your consultation. We will see the patient and discuss with patient.
            1. Please check anti Hbc
            1. Arrange port A insertion
  • surgical operation
    • 2022-06-22
      • Surgery
        • Laryngomicrosurgery with esophagoscopy for tumor mapping
      • Finding
          1. Left pyriform sinus medial wall tumor
          1. Smooth mucosal over posterior pharyngeal wall, postcricoid region, and cervical esophagus
    • 2013-10-07
      • Surgery
          1. Wide excision of left buccal malignant lesion
          1. Extraction of teeth of #27,#28,#37 and #38
          1. Supraomohyoid neck dissection, left
          1. Skin graft at the left buccal mucosa (donnor side is left thigh)
          1. OBTURATOR BY USE OF Buccal stent fixation
      • Finding
          1. Unhealed ulcerative lesion at the left buccal mucsoa about 1.5 cm in diameter.
          1. the tooth attrition by #27 is noted.
          1. malposition of #27,#28,#37 and #38
  • chemoimmunotherapy
    • 2022-07-20 - docetaxel 30mg/m2 1hr + cisplatin 30mg/m2 24hr + 5-Fu 1600mg/m2 48hr
    • 2022-07-14 - docetaxel 30mg/m2 1hr + cisplatin 30mg/m2 24hr + 5-Fu 1600mg/m2 48hr

==========

2022-07-20

  • There are three oral hypoglycemic drugs - Forxiga (dapagliflozin 10mg), Amamet (glimepiride 2mg + metformin 500mg), Lodiglit (pioglitazone 15mg + metformin 850mg), as well as a long-acting insulin - Tujeo - used as the basal dose.
  • F/S records and administered insulin units
    • Date QDAC basal QLAC basal
    • Unit mg/dL unit mg/dL unit
    • 2022-07-20 NA 16 - -
    • 2022-07-19 231 16 - -
    • 2022-07-18 254 16 - -
    • 2022-07-17 241 16 - -
    • 2022-07-16 193 16 - -
    • 2022-07-15 164 16 - -
    • 2022-07-14 189 16 - -
    • 2022-07-13 154 16 - -
    • 2022-07-12 237 - 176 16
  • According to the patient, 2022-07-19, he was well-tolerated with last chemotherapy that had been started on 2022-07-14, with the exception of somewhat oral mucosal pain just developed. He also had good appetite during those post-therapy days, so he consumed more than usual and the serum glucose levels increased since 2022-07-17.
  • The basal dose might be increased by 1 units if the glucose level still keeps above 200 mg/dL and his intake remains unchanged. In the event of hypoglycemia caused by a sulfonylurea - glimepiride, adjustment by only one unit should a precautionary measure.
  • Newly developed oral candidiasis is treated with oral suspension Mycostatin (nystatin).
  • The patient has alcoholic cirrhosis history with normal AST/ALT, bilirubin (total and direct) levels (2022-07-20), the doses of the chemotherapy regimen were adequate.

2022-07-12

  • The self-carried items Cardiolol (propranolol) and warfarin should be indicated for cardiovascular conditions, the current panel does not provide a cardiovascular diagnosis or condition yet.
  • Hx: type 2 DM. 2022-07-12 06:05 blood sugar level was 237 mg/dL. 2022-06-21 lab serum glucose AC 299 mg/dL.
    • Toujeo (insulin glargine) was prescribed by another hospital or clinic for this patient and could be considered to include it as a self-carried drug item for in-hospital use.
    • There are three oral hypoglycemic agents - Forxiga (dapagliflozin (SGLT2i) 10mg), Amamet (glimepiride (Sulfonylureas) 2mg + metformin 500mg), Lodiglit (pioglitazone (thiazolidinedione, TZD) 15mg + metformin 850mg) in active prescription.
      • If liver dysfunction becomes significant, please check for lactic acidosis. Liver disease is considered a risk factor for the development of lactic acidosis during metformin therapy.
      • Lodiglit contains pioglitazone. Pioglitazone should be use with caution if baseline liver tests are abnormal. If liver injury is suspected (eg, fatigue, jaundice, dark urine), please interrupt therapy, measure serum liver tests, and investigate possible etiologies.
    • HbA1c might be checked.
  • Consideration of dose adjustment for patients with impaired liver function, possible regimen might be: gemcitabine/cisplatin, docetaxel/cisplatin/5-FU
    • 5-Fu. The following adjustments have been suggested:
      • Bilirubin >5 mg/dL: Avoid use (Floyd 2006).
      • Hepatic impairment (degree not specified): Administer <50% of dose, then increase if toxicity does not occur (Koren 1992).
    • Docetaxel
      • Hepatic impairment dosing adjustment specific for gastric or head and neck cancer:
        • AST/ALT >2.5 to <=5 times ULN and alkaline phosphatase <=2.5 times ULN: Administer 80% of dose.
        • AST/ALT >1.5 to <=5 times ULN and alkaline phosphatase >2.5 to <=5 times ULN: Administer 80% of dose.
        • AST/ALT >5 times ULN and /or alkaline phosphatase >5 times ULN: Discontinue docetaxel.
      • The following adjustments have also been used (Floyd 2006):
        • Transaminases 1.6 to 6 times ULN: Administer 75% of dose.
        • Transaminases >6 times ULN: Use clinical judgment.
    • Cisplatin
      • It undergoes nonenzymatic metabolism and predominantly renal elimination. Dosage adjustment is likely not necessary.
    • Gemcitabine
      • Serum bilirubin >1.6 mg/dL: Use initial dose of 800 mg/m2; may escalate if tolerated.

701003664

220720

{cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB}

  • exam finding
    • 2022-07-14 KUB
      • S/P double J catheter insertion, left side urinary tract.
      • S/P clips projecting at right pelvis.
      • Ascites is noted. Please correlate with CT.
      • Segmental dilatation of bowel in the middle abdomen is noted. Please correlate with CT.
    • 2022-06-23 ECG
      • Sinus tachycardia
      • ST & T wave abnormality, consider inferior ischemia
      • ST & T wave abnormality, consider anterior ischemia
      • Abnormal ECG
    • 2022-06-23 KUB
      • S/P left side double J catheter insertion.
      • S/P operation with retention of surgical clips.
      • Presence of ileus.
    • 2022-06-10 2D transthoracic echocardiography
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild PR
    • 2022-06-03 CT - brain
      • No evidence of intracranial hemorrhage.
    • 2022-06-03 ECG
      • Normal sinus rhythm
      • ST & T wave abnormality, consider anterior ischemia
      • Prolonged QT
      • Abnormal ECG
    • 2022-05-18 ECG
      • Normal sinus rhythm
      • Nonspecific ST and T wave abnormality
    • 2022-05-17 SONO - abdomen
      • Diagnosis
          1. left abdominal wall mass, suspected tumor recurrence
          1. intestinal obstruction, DDx: carcinomatosis or adhesion
          1. right inguinal LAPs
      • Suggestion
        • refer to GYN
    • 2018-09-26 Gynecologic ultrasonography
      • suspected Rt corpus luteum cyst
    • 2018-09-23 CT - abdomen
      • Right hydronephrosis and hydroureter
      • Right distal ureter lesion; DDx: tumor invasion, post-RT change
      • Heterogeneous enhancing lesions in both lobes of liver. Suggest dynamic CT or sonography correlation.
    • 2018-04-04 Surgical pathology level V
      • clinical diagnosis
        • Mucous polyp of cervix; Subacute and chronic vaginitis;
      • pathological diagnosis
        • Uterus, cervic, LEEP conization
          • — Well to moderately differentiated adenocarcinoma
          • — carcinoma in situ
          • — margin inadequate (< or = 1mm of closest margin diatnce).
        • IHC satin — p16(+), CEA(focal+), vimentin (-)
      • microscopic description
        • It shows adenocarcinoma composed of prolieration of neoplastic glands lined by atypical cells and infiltrative growth pattern. The tumor shows hyperchromatic nuclei, plemorphism and promine tnucleoli. It also shows carcinoma in sit characterized by atypical cells replacing the fuul-thickness of the cervical epithelium with glandular involvement. The margin is inadequate (< or = 1mm of closest margin diatnce).
    • 2018-04-04 Surgical pathology level IV
      • clinical diagnosis
        • Mucous polyp of cervix; Subacute and chronic vaginitis;
      • pathological diagnosis
        • Uterus, endocervix, ECC — Mild glandular dysplasia
      • microscopic description
        • It shows endocervical mucosal tissue fragments with focal mild glandular dysplasia.
    • 2018-02-27 MRI - pelvis
      • Imaging Report Form for Cervical Carcinoma
        1. Soft tissue tumor in right cervical region (fornix), suspected cervical malignancy, cstage T1N0Mx.
        1. Prominent density in the uterine cavity, suggest further study.
        1. Uterine myoma.
    • 2018-02-14 Surgical pathology level IV
      • Screening for malignant neoplasms of cervix; Mucous polyp of cervix;
      • Diagnosis
        • Uterus, cervix, clinically R/O cervical cancer — Adenocarcinoma in situ (AIS), at least.
        • NOTE: Since invasive malignancy is suspected clinically, further work up is advised.
      • Microscopic description
        • Section shows pieces of adenocarcinoma in situ (AIS), at least, with papillary structures lined by epithelium demonatrsting elongated nuclei, occasional nuclear pleomorphism, and many mitoses. Occasional cribriform pattern glands are found.
  • consultation
    • 2022-06-27 Chinese Medicine
      • Q
        • This 42-year-old woman patient is a case of Cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB,
          • s/p Robotic radical trachelectomy + pelvic lymphadectomy on 2018/04/23 at Far Eastern Memorial Hospital with pelvic recurrence and compression to lower part of right ureter and right ovary s/p Robotic pelvic adhesiolysis, pelvic mass biopsy, right salpingo-oophorectomy and left ovary suspension on 2018/11 at Far Eastern Memorial Hospital
          • s/p salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx) (2018/12~2019/02) at Far Eastern Memorial Hospital s/p radial trachelectomy and left ovarian transposition on 2019/05/31 at Far Eastern Memorial Hospital with left upper abdominal wall port site metastases,
          • s/p excision of abdomnal wall tumor on 2020/7/09, 2020/11/24, 2021/03/16 s/p systemic chemotherapy with 6 cycles of Cisplatin 50mg/m2 + Paclitaxel 175 mg/m2 + Bevacizumab 15mg/kg at Far Eastern Memorial Hospital (2021/03~?)
          • s/p left abdominal radiotherapy for the port-site metastatses x 10 times at Koo Foundation Sun Yat-Sen Cancer Center (2022/02~).
        • This time, ileus with nauseas with vomiting admitted for further treatment. Now, for evaluate Comprehensive protocol of integrated Chinese and western medicine (ICWM). Thank you.
      • A
        • past history
          • 2018/07/27 Uterine myoma
        • 2022-04 CT at KFSYSCC
          • Clinical History and Indications Metastatic Cervical adenocarcinoma:
              1. Larger of the lower abdominal wall lesion. R/I metastasis; and peritoneal / bowel wall invasion suspected. Right inguinal lymph node (8.6 mm), larger.
              1. Dilatation of small bowel, which may related to adhesion or peritoneal carcinomatosis.
        • 2022-06-27 lab data
          • S-GPT/ALT = 249 U/L;
          • S-GOT/AST = 112 U/L;
          • Albumin = 2.8 g/dL;
          • BUN = 20 mg/dL;
          • Bilirubin direct = 0.25 mg/dL;
          • eGFR = 90.07;
          • WBC = 1.52 *10^3/uL;
          • RBC = 3.68 *10^6/uL;
          • HGB = 10.0 g/dL;
          • PLT = 50 *10^3/uL;
          • Neutrophil = 65.0 %;
        • Plan
          • By using acupuncture to improve the symptom of intestinal obstruction
    • 2022-05-22 Hemato-Oncology
      • Q
        • This 42-year-old woman,G0P0, sex(+), with medical/surgical history of
            1. Cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB, - s/p Robotic radical trachelectomy + pelvic lymphadectomy on 2018/04/23 at FEMH
            • with pelvic recurrence and compression to lower part of right ureter and right ovary, s/p Robotic pelvic adhesiolysis, pelvic mass biopsy, right salpingo-oophorectomy and left ovary suspension on 2018/11 at FEMH
            • s/p salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx) (2018/12~2019/02) at FEMH
            • s/p radial trachelectomy and left ovarian transposition on 2019/05/31 at FEMH
            • with left upper abdominal wall port site metastases, s/p excision of abdomnal wall tumor on 2020/7/09, 2020/11/24, 2021/03/16
            • s/p systemic chemotherapy with 6 cycles of Cisplatin 50mg/m2 +Paclitaxel 175 mg/m2 + Bevacizumab 15mg/kg at FEMH (2021/03~?)
            • s/p left abdominal radiotherapy for the port-site metastatses x 10 times at KFSYSCC (2022/02~)
            1. Bilateral lower ureteral stricture with bilateral hydronephrosis,
            • s/p bilateral DBJ insertion since 2018/04
            • s/p left ureterolysis + right ureteroneocystostomy with psoas hitch and Boari flap on 2019/05/31
        • This time, abdominal discomfort (intermittent cramping pain) and body weight loss (8kg) were noted since 2022/03/26.
          • Abdominal CT scan showed
              1. Larger of the lower abdominal wall lesion. R/I metastasis; and peritoneal / bowel wall invasion suspected;
              1. Dilatation of small bowel, which may related to adhesion or peritoneal carcinomatosis.
          • Blood drawn on 2022/04/25 showed CA153 17.2, CA199 655.1 and CA125 137.3.
          • She visited to our GI hospital on 2022/05/17 where sonography showed
              1. Left abdominal wall mass, suspected tumor recurrence
            • 2.Intestinal obstruction, DDx: carcinomatosis or adhesion
            • 3.Right inguinal LAPs.
        • Under the impression of cervical adenocarcinoma suspected metastasis and recurrence, she was then referred to Prof. Huang and admission to our ward for further evaluation and management, we need your expertise for further evaluation and management.
          • s/p salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx) (2018/12~2019/02) at FEMH
          • s/p systemic chemotherapy with 6 cycles of Cisplatin 50mg/m2 +Paclitaxel 175 mg/m2 + Bevacizumab 15mg/kg at FEMH (2021/03~?)
      • A
        • Suggestion:
            1. For recurrent or metastasis cervical cancer, systemic chemotherapy is indicated. We will discuss with patient about further systemic chemotherapy.
            1. Thanks for your consultation. If there is any problem, please feel free to let us known.
  • surgical operation
    • 2020-07-09, 2020-11-24, 2021-03-16
      • with left upper abdominal wall port site metastases, s/p excision of abdomnal wall tumor
    • 2019-05-31 at FEMH
      • radial trachelectomy and left ovarian transposition
      • left ureterolysis + right ureteroneocystostomy with psoas hitch and Boari flap
    • 2018-11-?? at FEMH
      • Robotic pelvic adhesiolysis, pelvic mass biopsy, right salpingo-oophorectomy and left ovary suspension
    • 2018-09-23
      • Diagnosis
        • Right hydronephrosis
      • PCS code
        • 28020C
      • Finding
        • Right lower ureter stricture 4cm proximal to ureteral orifice
        • External compression was clinically suspected
        • 6Fr 24cm DBJ was inserted
    • 2018-04-23 at FEMH
      • Robotic radical trachelectomy + pelvic lymphadectomy
    • 2018-04-04
      • Diagnosis
        • Mucous polyp of cervix
      • PCS code
        • 81031C
      • Finding
          1. Cervix:papillary lesion oner right external OS
          1. Three strips211, 111,0.5*0.5 cm strip of cervix were electrocauterized.
          1. Estimated blood loss:50ml
          1. Complication: nil
  • radiotherapy
    • 2022-02 ~ ? at KFSYSCC
      • left abdominal radiotherapy for the port-site metastatses x 10 times
    • 2018-12 ~ 2019-02 at FEMH
      • salvage CCRT with 6 cycles of chemotherapy with Cisplatin 40mg/m2 & pelvic radiotherapy (6000cGy/30fx)
  • chemoimmunotherapy
    • 2022-06-13, 2022-07-04 - topotecan 0.75mg/m2 30min D1-3 + cisplatin 25mg/m2 24hr D1-2
    • 2021-03 ~ ? at FEMH - 6 cycles of cisplatin 50mg/m2 + paclitaxel 175 mg/m2 + bevacizumab 15mg/kg
    • 2018-12 ~ 2019-02 at FEMH - 6 cycles of chemotherapy with cisplatin 40mg/m2 for CCRT
  • chemotherapy regimen reference

==========

2022-07-20

  • I visited the patient and her mother at approximately 16:45 on 2022-07-19.
  • As compared with the experience at FEMH/KFSYSCC, the patient tolerates the current regimen well for less nausa and vomiting.
  • The patient is concerned that the treatment will adversely affect her kidney function. According to the recent lab results, I told her that there is no problem with her kidney function.

2022-07-19

[BFluid - the amount of electrolyte can be added]

A supplement to my explanation after answering the nurse’s call this morning about the compatibility of B Fluid with KCl.

  • Each 1000 mL BFluid solution contains (after mixing)
    • Electrolytes mEq/L, max amount to be added
      • Na+ 35 115
      • K+ 20 40
      • Ca++ 5 5
      • Mg++ 5 16
      • HPO4– 10 10
      • insulin 0 10~20 (IU)
  • The addition of other drugs to BFluid is not recommended except for electrolytes and regular insulin.
  • Within the limits of the amount, KCl is compatible with B Fluid. It contains 20mEq K+ in the prescribed 0.298% KCl 500mL.

701381642

220720

{Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis}

  • exam finding
    • 2022-07-19 SONO - thorax
      • Echo diagnosis
        • Left thorax: organized pleural effusion
        • Right thorax: moderate amount, yellowish pleural effusion s/p insertion of 14 Fr. pig-tail catheter and fixed at 15cm.
    • 2022-07-16 CXR
      • Total white-out of left lung is noted that may be massive pleura effusion?
      • Right pleura effusion.
      • Several nodular opacity projecting in the right lung are noted that are c/w lung to lung metastases. Please correlate with CT.
      • Enlargement of cardiac silhouette.
      • Metastasis in right 5th rib is suspected.
    • 2022-07-14 ECG
      • Sinus tachycardia
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-07-14 SONO - thorax
      • Symptoms: dyspnea improved
      • Indication: effusion, LUL
      • Clinical Diagnosis
        • Thymic cancer with persited left side pleural effusion, LUL consolidation with airbronchogram. localized pleural effusion, with LUL consolidation.
      • Procedure & Finding
        • The patient was in sitting upright posture while the chest echography was performed using 3.75-mHz convex probe.
        • Left-side of thorax
          • Pleura positive Pleura Line thin
          • Effusion: Echogenicity clear localized
          • Size 1-2-ICS, Left upper lung, fixed, with LUL consolidation, collapse.
          • Left lower back pleural thickening with fixed, organization of pleural effusion or parietal pleural involvement.
        • Right-side of thorax:
          • Pleura negative Pleura Line
      • Special Procedure: Nil
      • Echo diagnosis:
        • Left side:
          • Size 1-2-ICS, Left upper lung, fixed, with LUL consolidation, collapse.
          • Left lower back pleural thickening with fixed, organization of pleural effusion or parietal pleural involvement.
      • Removal of pig tail tube due to obstruction by debri.
      • Pig tail re-insertion was not safe because of a little pleural effuion only.
      • Suggestion:
        • CxR follow up 3-7 days. or chest echography if SOB develope again.
    • 2022-06-24 CXR
      • Patchy opacity projecting at left upper lung zone with lung volume decrease and air-bronchogram was noted. Please correlate with CT.
      • Several nodular opacity projecting in the right lung are noted that are c/w lung to lung metastases. Please correlate with CT.
      • Enlargement of cardiac silhouette.
      • Left pleura effusion S/P pigtail catheter implantation.
      • S/P port-A implantation.
      • Metastasis in right 5th rib is suspected.
    • 2022-06-20 CXR
      • Patchy opacity projecting at left upper lung zone with lung volume decrease was noted. Please correlate with CT.
      • Several nodular opacity projecting in the right lung are noted that are c/w lung to lung metastases. Please correlate with CT.
      • Enlargement of cardiac silhouette.
      • Left pleura effusion S/P pigtail catheter implantation.
      • S/P nasogastric tube insertion
      • S/P port-A implantation.
      • Metastasis in right 5th rib is suspected.
    • 2022-06-16 CXR
      • appropriately positioned gastric tube
      • Port-A catheter inserted into RA via right subclavian vein.
      • LUL lobar consolidaition with air-bronchogram
      • consolidation over Lt lower lung with enlarged hilum
      • nodular/patchy opacities in Rt lung in progression
      • enlarged cardiac silhoutte
      • Rt pleural effusion
      • Lt pleural effusion s/p pigtail drain placement
    • 2022-06-16 CXR
      • appropriately positioned gastric tube
      • approriately positioned endotracheal tube in place
      • Port-A catheter inserted into RA via right subclavian vein.
      • LUL lobar consolidaition with air-bronchogram
      • extensive consolidation over Lt lower lung with enlarged hilum
      • nodular/patchy opacities in Rt lung
      • enlarged cardiac silhoutte
      • Rt pleural effusion
      • Lt pleural effusion s/p pigtail drain placement
    • 2022-06-09 CXR
      • Port-A catheter inserted into RA via right subclavian vein.
      • LUL lobar consolidaition with air-bronchogram
      • extensive consolidation over Lt lower lung with enlarged hilum
      • nodular/patchy opacities in Rt lung
      • enlarged cardiac silhoutte
      • Rt pleural effusion
      • appropriately positioned gastric tube
      • approriately positioned endotracheal tube in place
      • regression Lt pleural effusion s/p pigtail drain placement
    • 2022-06-06 CXR
      • Port-A catheter inserted into RA via right subclavian vein.
      • LUL lobar consolidaition with air-bronchogram
      • extensive consolidation over Lt lower lunbg with enlarged hilum
      • numerous nodules/parchy opacities of variable sizes in Rt lung due to metastases
      • enlarged cardiac silhoutte
      • bilateral pleural effusions
      • appropriately positioned gastric tube
      • approriately positioned endotracheal tube in place
      • regression Lt pleural effusion s/p pigtail drain placement
    • 2022-06-02 SONO - chest
      • Clinical Diagnosis
        • Thymic cancer stage 4
        • Left side pleural effusion
      • Procedure & Finding
        • The patient was in supine posture while the chest echography was performed using 3.75-mHz convex probe.
          • Left-side of thorax
            • Pleura positive Pleura Line thin
            • Effusion: Echogenicity clear extending from the posterior to the anterior
            • Size 1-2-ICS
          • Right-side of thorax
      • Echo diagnosis:
        • Left side mild to moderate pleural effusion s/p pig-tail insertion, seroanguinous, drowsy
    • 2022-06-02 2D transthoracic echocardiography
      • Normal chamber size
      • Small pericardial effusion
      • Adequate LV and RV systolic function
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
    • 2022-05-31 ECG
      • Sinus tachycardia
      • Nonspecific T wave abnormality
    • 2022-05-30 ECG
      • Sinus tachycardia
      • Low voltage QRS
      • Poor wave progression
      • Abnormal ECG
  • consultation
    • 2022-06-16 Nephrology
      • Q
        • This 45y/o female was a case of Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis. Regular in NTUH follow-up.
        • According to the statement of the patient families and ER medical record. She ever fever, suspected community-acquired pneumonia, status post Unasyn 3/29-4/8 under Augmentin. This time. she had suffered from palpitations, dyspnea, spiky fever and generalized malaise for 2 days, the symptoms became to worsen. Therefore she was sent to our ER.
        • At ER, spiky fever up to 38.1degree, Acetamol iv infusion and adequate fluid iv infusion were given. Elevation of breathing work and saturation around 80%, the patient refused invade procedule, NIPPV placement and steroid with solu-cortef 50mg iv injection. The chest films disclosed of bilateral pneumonia with massive plerual effusion, empiric antiboltic with Tapimycin was perscribed. Bordelrine blood pressure around SBP 95-99mmHg, Albumin 50ml IVD loading and fluid iv infusion for hydration.
        • Under the impression of sepsis and bilateral pneumonia with massive plerual effusion combine impending respiratory failure. She was admitted to our ICU for further observation and management.
        • Due to the very low creatinine level, electrolyte unbalance, short stature, we have check Aldosterone and PRA (plasma renin activity) according to the suggestion of endocrinologist and we need your expertise of further evaluation and management of the very low creatinine level, electrolyte unbalance, short stature. Thanks!
      • Q
        • Impression
          • Low creatinine due to low muscle mass, or cachexia related
          • Mg deficiency suspect nutritional deficiency related
        • Suggestion
          • Check 24h Cr
          • Nutrition supplement
        • Thank you very much for your consultation.
    • 2022-06-15 Metabolism and Endocrinology
      • c-peptide < 0.02 ng/mL
      • very poor beta cell function,
      • high risk for DKA and sugar unstable as same as DM type 1
      • please check Anti-GAD (GAD Ab, Glutamic Acid Decarboxylase Autoantibodies test), (self-paid item) to rule in DM type 1
      • re-on basal insulin with bolus insulin to control blood sugar
      • please check insulin Ab - –
      • very low Cr, electrolyte unbalance, short stature
      • glomerular hyperfiltration?
      • please check Aldosterone and PRA (plasma renin activity)
      • please Consult Nephrologist
      • may consult Pediatrics Dr. Tsai to rule out genetic disorder
      • please consult Oncologist
    • 2022-06-13 Gastroenterology
      • Q
        • We need your expertise for entecavir use before the chemotherapy use. Thanks!
      • A
        • Entecavir would be prescribed.
        • Indication: HbsAg(+) or HbsAg(-) while anti-Hbc(+) plus chemotherapy (1 wk before C/T unitl 6 mo after C/T)
    • 2022-06-09 Metabolism and Endocrinology
      • Q
        • Due to the poor control hyperglycemia condition, we need your expertise of further evaluation and management of medication control under insulin use. Thanks!
      • A
        • O:
          • BW: 43.2
          • Diet: NG, DM diet 1800 kcal/day
          • Medication in OPD: Metformin, Trajenta, NovoRapid, Toujeo
          • Medication during hospitalization: RI TIDAC, Toujeo, Metformin
          • Na: 132, K: 4.1
          • ALT: 7
          • BUN/Cr: 13/0.35 (eGFR: 213.07)
          • F/S (finger stick):
            • date 06-07 06-08 06-09
            • QDAC 277 357 281 -> RI 16u
            • QLAC 466 328 272 -> RI 16u
            • QNAC 240 393 91 -> Hold RI
            • HS 072 054 308
          • HbA1c: 6.5
          • Urine ACR: unavailable
          • OPH OPD: nil
        • A:
          • Type 2 DM, poor controlled
        • Suggestions:
            1. Avoid all OADs at this moment (DC Metformin during infection status)
            1. RI 14U QDAC (before first meal), 12U QLAC (before third meal), 10U QNAC (before fifth meal) with correction scales -> switch to apidra low dose before each feeding
            • F/S < 080,RI hold
            • F/S 081~090,RI -4U
            • F/S 091~100,RI -3U
            • F/S 101~110,RI -2U
            • F/S 111~120,RI -1U
            • F/S 201~250,RI +1U
            • F/S 251~300,RI +2U
            • F/S 301~350,RI +3U
            • F/S 351~400,RI +4U
            • F/S > 400,RI +5U
            1. Hold Toujeo temporarily
            1. Check urine ACR
            1. Contact us if needed. I’d like to follow up this patient. - –
        • low body weight 42-43 kg
        • sugar unstable under RI 12u tidac and basal insulin
        • Switch RI tidac to apidra before each feeding
        • Please call Dr. Hu QD or QOD to adjust insulin dosage if sugar poor control
        • Please check blood sugar and C-peptide to evaluate beta cell function
        • Fluoroquinolones may increase the risk of hypoglycemia, please closely monitor finger stick and hypoglycemia
        • consider switch Toujeo to Tresiba
    • 2022-06-03 Hemato-Oncology
      • Q
        • Due to Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis. Regular in NTUH follow-up. Patient family stated that NTUH had thought to apply oral targeted drugs, need your evluation help and check targeted drugs, thanks a lot!!
      • A
        • Impression:
            1. Bilateral pneumonia with respiratory failure s/p endo with ventilation
            1. Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis
        • Suggestion:
            1. Treat sepsis and respiratory failure as your expertise, best supportive care
            1. Have the patient family to bring medical records from NTUH
            1. Thanks for your consultation. If there is any problem, please feel free to let us known.
    • 2022-06-01 Infectious Diseases
      • Antibiotic therapy should be adjusted according to the results of in vitro sensitivity testing.
      • NO treatment for colonization. Do NOT use steroid.
      • Antimicrobiologic coverage with parental Finibax 500 mg q8h is recommended.
    • 2022-05-31 Family Medicine
      • Q
        • This consultation is for critically ill hospice care.
        • After admission, elevation of breathing work with paradoxical movement used and desaturation were found. We have informed prognosis and intubation indication with treatment programs to his hunsband, he understood and decided aggresive treatment. Due to these resasons, we sincerely need your expertise for critically ill hospice care. Thanks!
      • A
        • Patient has received intubation and just undergoes aggressive treatment.
        • We will arrange share care to F/U her prognosis.
        • We could arrange transfer if necessary.
        • Indication: Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB
  • chemoimmunotherapy
    • 2022-06-13 ~ undergoing - cisplatin 20mg/m2 24hr + 5-Fu 2000mg/m2 24hr + leucovorin 200mg/m2 24hr (weekly)

[note]

  • Thymomas and Thymic Carcinomas, NCCN EB, Version 2.2022 - May 4, 2022, p13
    • Principles of systemic therapy - first-line combination chemotherapy regimens
      • Thymoma
        • Preferred (Other Recommended for Thymic Carcinoma)
          • CAP1
            • Cisplatin 50 mg/m2 IV day 1
            • Doxorubicin 50 mg/m2 IV day 1
            • Cyclophosphamide 500 mg/m2 IV day 1
            • Administered every 3 weeks
        • Other Recommended for Thymic Carcinoma and Thymoma
          • CAP with prednisone
            • Cyclophosphamide 500 mg/m2 IV on day 1;
            • Doxorubicin, 20 mg/m2/day IV continuous infusion on days 1-3;
            • Cisplatin 30 mg/m2 days 1-3;
            • Prednisone 100 mg/day days 1-5;
            • Administered every 3 weeks
          • ADOC
            • Doxorubicin 40 mg/m2 IV day 1;
            • Cisplatin 50 mg/m2 IV day 1;
            • Vincristine 0.6 mg/m2 IV day 3;
            • Cyclophosphamide 700 mg/m2 IV day 4
            • Administered every 3 weeks
          • PE
            • Cisplatin 60 mg/m2 IV day 1;
            • Etoposide 120 mg/m2/day IV days 1-3;
            • Administered every 3 weeks
          • Etoposide/ifosfamide/cisplatin5
            • Etoposide 75 mg/m2 on days 1-4;
            • Ifosfamide 1.2 g/m2 on days 1-4;
            • Cisplatin 20 mg/m2 on days 1-4
            • Administered every 3 weeks
      • Thymic Carcinoma
        • Preferred (Other Recommended for Thymoma)
          • Carboplatin/paclitaxel
            • Carboplatin AUC 6
            • Paclitaxel 200 mg/m2
            • Administered every 3 weeks
    • Principles of systemic therapy - second-line chemotherapy regimens (subsequent therapy)
      • Thymoma
        • Other Recommended
          • Etoposide
          • Everolimus
          • 5-FU and leucovorin
          • Gemcitabine +- capecitabine
          • Ifosfamide
          • Octreotide (including LAR) +/- prednisone
          • Paclitaxel
          • Pemetrexed
      • Thymic Carcinoma
        • Other Recommended
          • Everolimus
          • 5-FU and leucovorin
          • Gemcitabine +- capecitabine
          • Lenvatinib
          • Paclitaxel
          • Pembrolizumab
          • Pemetrexed
          • Sunitinib
        • Useful in Certain Circumstances
          • Etoposide
          • Ifosfamide

==========

2022-07-20

  • F/S records and administered insulin units
    • Date QDAC basal bolus QLAC bolus QNAC bolus
    • Unit mg/dL unit unit mg/dL unit mg/dL unit
    • 2022-07-20 184 12 7 - - - -
    • 2022-07-19 157 12 7 256 8 141 7
    • 2022-07-18 277 12 7 360 7 316 7
    • 2022-07-17 105 12 7 301 7 361 7
    • 2022-07-16 265 12 7 274 7 179 7
    • 2022-07-15 060 0 0 280 7 186 7 (QDPC 190 mg/dL, after taking sugar)
    • 2022-07-14 189 12 7 281 7 319 7
    • 2022-07-13 - - - - - 376 7
  • According to the patient’s mother last evening, she had been feeling weaker these two days and had also reduced her calorie intake. In spite of the high blood sugar levels before lunch these days, there is no urgent need to adjust the insulin dose for her recent low intake at this time.

2022-07-18

  • Insulins in active prescription
    • Apidra 100U/mL (insulin glulisine) 7 unit SC TIDAC
      • onset 5~15min, max 30~90min, duration 3~5hr
    • Tresiba FlexTouch 100U/mL (insulin degludec) 12 unit SC QDAC
      • onset 1hr, no apparent peak, duration >24hr
  • F/S records
    • Date QDAC QLAC QNAC HS
    • 2022-07-18 277 360 - -
    • 2022-07-17 105 301 361 NA
    • 2022-07-16 265 274 179 NA
    • 2022-07-15 060 280 186 NA (QDPC 190, after taking sugar)
    • 2022-07-14 189 281 319 NA
    • 2022-07-13 NA NA 376 NA
  • On 2022-07-15 morning before breakfast, hypoglycemia was observed, but it is unclear what transpired between 7/14 bedtime and the event.
  • Last week I noted that the patient’s staple food was porridge, and her snack was bread, which are easy to raise blood sugar levels, and her each meal might not be taken in similar quantity, thus complicating blood sugar control.
  • As there was a hypoglycemia event last week, the basal dose can be kept as usual, however, the F/S readings remain high these days. It is recommended that the QLAC bolus be increased by +2U, and the QNAC bolus by +1U.

2022-07-15

  • There were no visual problems perceived by the patient when I visited her 09:10 2022-07-15. As there is no ophthalmology OPD record found, it would be recommended to consult Oph if diabetic retinopathy is suspected.

2022-07-14

  • CNS depressants alprazolam, brotizolam, lorazepam, oxazolam were prescribed as HS co-administered, adverse/toxic effect might be enhanced.
  • The half-life of each item (short to long): brotizolam (3.5 ~ 8 hr), oxazepam (5 ~ 15 hr), alprazoalm (6 ~ 12 hr), lorazepam (10 ~ 20 hr), it may be considered to remove drugs that have similar effect time.

700034769

220719

  • lab data
    • Creatinine
      • 2022-07-19 1.80 mg/dL
      • 2022-07-11 2.25 mg/dL
      • 2022-07-05 2.31 mg/dL
      • 2022-06-28 2.04 mg/dL
      • 2022-06-13 2.31 mg/dL
      • 2022-05-28 2.23 mg/dL
      • 2022-05-17 2.29 mg/dL
      • 2022-05-05 2.47 mg/dL
      • 2022-05-03 2.40 mg/dL
      • 2022-04-29 2.94 mg/dL
      • 2022-04-28 2.11 mg/dL
      • 2022-04-25 1.90 mg/dL
      • 2022-04-17 1.70 mg/dL
      • 2022-04-15 2.03 mg/dL
      • 2022-03-29 1.84 mg/dL
      • 2022-03-21 2.16 mg/dL
      • 2022-03-17 1.99 mg/dL
      • 2022-03-16 1.77 mg/dL
      • 2022-03-15 1.95 mg/dL
      • 2022-03-01 1.68 mg/dL
      • 2022-02-21 1.73 mg/dL
      • 2022-02-15 1.78 mg/dL
      • 2022-02-07 1.30 mg/dL
      • 2022-01-24 1.40 mg/dL
      • 2022-01-17 1.38 mg/dL
      • 2022-01-14 1.45 mg/dL
      • 2022-01-11 1.35 mg/dL
      • 2022-01-03 1.11 mg/dL
      • 2021-12-28 1.41 mg/dL
      • 2021-12-21 1.41 mg/dL
      • 2021-12-16 1.52 mg/dL
      • 2021-12-14 1.36 mg/dL
      • 2021-12-06 1.11 mg/dL
      • 2021-11-26 1.07 mg/dL
      • 2021-10-05 1.44 mg/dL
      • 2021-09-07 1.22 mg/dL
      • 2021-07-13 1.25 mg/dL
      • 2021-03-23 1.13 mg/dL
      • 2021-01-26 1.07 mg/dL
      • 2020-10-06 1.18 mg/dL
      • 2020-09-04 1.20 mg/dL
    • BUN
      • 2022-07-19 44 mg/dL
      • 2022-07-11 31 mg/dL
      • 2022-06-28 38 mg/dL
      • 2022-05-28 34 mg/dL
      • 2022-05-05 28 mg/dL
      • 2022-05-03 33 mg/dL
      • 2022-04-29 46 mg/dL
      • 2022-04-28 32 mg/dL
      • 2022-04-25 43 mg/dL
      • 2022-04-17 28 mg/dL
      • 2022-04-15 35 mg/dL
      • 2022-03-16 34 mg/dL
      • 2022-02-21 27 mg/dL
      • 2022-02-07 20 mg/dL
      • 2022-01-24 23 mg/dL
      • 2022-01-03 25 mg/dL
      • 2021-12-28 36 mg/dL
      • 2021-12-06 23 mg/dL
      • 2021-11-26 19 mg/dL
  • exam finding
    • 2022-06-20 CXR
      • S/P port-A implantation.
      • Atherosclerotic change of aortic arch
    • 2022-05-28 CT - lung/mediastinum/pleura
      • Finding
        • Chest:
          • S/p port-A placement with its tip at Superior vena cava.
          • Wedge shaped interstitial opacity over left upper lobe is found. The lesion is new. Recent inflammation is considered.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Left renal stone is found.
          • The spleen, liver, pancreas and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is stone at dependent portion of GB. GB stone(s) are noted.
      • Imp:
        • Gallstones.
        • No evidence of lymphadenopathy in the study.
        • Wedge shaped interstitial opacity over left upper lobe is found. The lesion is new. Recent inflammation is considered.
    • 2022-04-28 ECG
      • Left ventricular hypertrophy with QRS widening
    • 2022-02-24 Renal SONO (Nephrology)
      • Bilateral renal cysts, cortical and parapelvic ones.
    • 2022-02-16 CT - neck
      • no evidence of left neck nodular leions.
    • 2021-12-18 Renal SONO (Nephrology)
      • Parenchymal renal disease
      • Bilateral renal cysts
      • Left renal stone
    • 2021-11-29 Patho - bone marrow biopsy
      • Bone marrow, iliac crest, biopsy — Negative for malignancy
      • Microscopically, it shows 40% of marrow cellularity, with 3:2 of M:E ratio, presence of trilineage cellular component and occasional megakaryocytes.
      • Immunohistochemical stain reveals CD34(-), CD117(-), CD20(-), CD138(< 5%), MPO(+), CD71(+), Bcl-2(-) and Bcl-6(+).
    • 2021-12-01 2D transthoracic echocardiography
      • Heart size: Dilated LA, AoR
      • Thickening: IVS, LVPW
    • 2021-11-26 ECG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2021-11-17 Whole body PET scan
      • Glucose hypermetabolism in the left neck lymph nodes and bilateral axillary lymph nodes comes to less evident compared with the previous study on 2017-08-18, indicating response to current therapy.
      • Glucose hypermetabolism in the left thyroid bed, the nature is to be determined (functioning nodule of thyroid, inflammatory process or other nature ?). Please correlate with other clinical findings for further evaluation.
      • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive nodes or physiologic FDG uptake is more likely.
    • 2021-11-08 Patho - lymphnode biopsy
      • Lymph node, left neck, excisional biopsy— Diffuse large B-cell lymphoma, non-GCB (c-myc +)
      • Immunohistochemical stain profiles: CD23(focal+), CD20(+), CD10(-), Ki-67 index: 20%, Bcl-2(+), c-myc (+, >30%), MUM1(+), Bcl-6(+), cyclin D1(-), CD3 (immunoreactive at background T cell).
      • Reference: S2017-12983
    • 2021-11-02 Nasopharyngoscopy
      • Findings
        • smooth NPx, oropharynx, hypopharynx, no tumor found
      • Diagnosis
        • lymphoma s/p treatment
    • 2021-10-20 CT - lung/mediastinum/pleura
      • Findings - comparison made with previous CT dated on 2021/04/13
          1. Lungs: a 14 mm cyst at S10 of RLL, otherwise normal appearance of bilateral lungs.
          1. Mediastinum: no enlarged LN or mass.
          1. Hila: no enlarged LN.
          1. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance..
          1. Heart: normal in size of cardiac chambers. midseptal hypertrophy of IVS.
          1. Pleura and pericardium: no effusion or thickening
          1. Chest wall and visible neck: multiple small lymph nodes in bilateral axillary regions and visible neck, stationary.
          1. Visible abdominal contents: a tiny Lt renal stone 2 mm. multiple small liver cysts up to 1.5 cm. many gall bladder stones. unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney. no enlarged LN.
      • IMP:
        • no mass or enlarged lymphadenopathy in visible neck, mediastinum and axillary regions, and abdomen.
    • 2021-04-13 CT - lung/mediastinum/pleura
      • Findings - comparison made with previous CT dated on 2020/10/27
          1. Lungs: a 14 mm cyst at S10 of RLL, otherwise normal appearance of bilateral lungs.
          1. Mediastinum: no enlarged LN or mass.
          1. Hila: no LAP.
          1. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
          1. Heart: normal in size of cardiac chambers. midseptal hypertrophy of IVS.
          1. Pleura and pericardium: no effusion or thickening
          1. Chest wall and visible neck: multiple small lymph nodes in bilateral axillary regions and posterior triangles of visible neck.
          1. Visible abdominal contents:
          • a tiny Lt renal stone 2 mm. multiple small liver cysts up to 1.5 cm. gall bladder stones.
          • unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney.
          • no mass or lymphadenopathy in visible neck, mediastinum and axillary regions, and abdomen.
    • 2020-10-27 CT - lung/mediastinum/pleura
      • Findings - comparison: prior CT dated on 2019/01/17
          1. Lungs and large central airways: normal appearance of bilateral lungs.
          1. Mediastinum: no LAP or mass.
          1. Hila: no LAP.
          1. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
          1. Heart: normal in size of cardiac chambers.
          1. Pleura, pericardium: no effusion or thickening
          1. Chest wall and neck: multiple small lymph nodes in bilateral axillary regions and posterior triangles of visible neck.
          1. Visible abdominal-pelvis contents:
          • a tiny Lt renal stone. multiple liver cysts up to 1.5cm
          • gall bladder stones.
          • unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney. U-bladder and small and large bowels are grossly unremarkbale.
      • Impression:
        • no mass or LAP in visible, mediastinum and axillary regions.
    • 2020-06-10 CT - neck
      • multiple bilateral lymph nodes in the neck spaces.
    • 2019-11-14 SONO - abdomen
      • Diagnosis
        • Suspected chronic liver parenchyma disease(Please correlate with liver function)
        • Suspected liver cyst, left
        • Suspected GB stones
        • Pancreas not shown
        • Suboptimal examination of liver due to poor echo window
      • Suggestion
        • OPD f/u
        • Follow liver function test and AFP
        • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
    • 2019-05-20 SONO - abdomen
      • Parenchymal liver disease
      • GB stones
      • Liver cysts
      • Renal cyst, right side
      • Fatty infiltration of pancreas
    • 2019-01-17 CT - lung/pleura
      • Findings - comparison: prior CT on 2018/08/27
          1. Lungs and large airways: normal appearance of bilateral lungs. as compared with previous CT study.
          1. Mediastinum: no LAP or mass.
          1. Hila: no LAP.
          1. Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance..
          1. Heart: normal in size.
          1. Pleura: no effusion or thickening
          1. Chest wall and neck: no enlarged lymph nodes.
          1. Visible abdominal contents:
          • a tiny Lt renal stone. multiple liver cysts up to 1.5cm
          • gall bladder stones.
          • unremarkable of the spleen, adrenal glands, pancreas, and Rt kidney
          • bile ducts: No dilatation.
          • no enlarged lymphadenopathy.
          1. Visualized bones: unremarkable.
      • Impression:
        • no recurrent neck lymphadenopathy.
        • no lesion in mediastinum and axillary regions.
    • 2018-08-27 CT - lung/pleura
      • Impression:
        • Bilateral axillary non-specific lymph nodes
    • 2018-05-03 CT - lung/pleura
      • Impression:
        • 3mm calcified granuloma in basal segments of LLL.
        • No LAPs in neck, chest and abdomen. gallstones. a 2mm left renal stone.
    • 2018-01-03 CT - lung/pleura
      • Impression:
        • Nonspecific micronodules in LLL.
        • No LAPs in chest and abdomen. gallstones.
    • 2017-09-04 CXR
      • Borderline heart size enlargement.
      • Mild tortuosity of thoracic aorta. No mediastinal widening.
      • Presence of increased lung infiltrations.
    • 2017-08-19 SONO - abdomen
      • fatty liver, mild/ incomplete exam of liver
      • liver cysts
      • gallstones
      • gallbladder polyps, suspect adenomyomatosis of GB wall
    • 2017-08-18 ECG
      • Normal sinus rhythm
      • Left ventricular hypertrophy with QRS widening
      • Abnormal ECG
    • 2017-08-18 Whole body PET scan
      • Glucose hypermetabolism involving a confluent left neck level II-III lymph node, compatible with lymphoma.
      • Mild glucose hypermetabolism in bilateral axillary lymph nodes and glucose hypermetabolism in the left aspect of the nasopharynx. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
      • Glucose hypermetabolism in the right upper anterior chest wall in linear shape. Post-operative inflammation may show this picture.
      • Increased FDG uptake in bilateral neck muscles. Physiologic FDG uptake is more likely.
    • 2017-08-09 Surgical pathology Level IV
      • Lymph node, left neck, core needle biopsy —– Diffuse large B cell lymphoma.
      • IHC stains: CK(-), CD3 (-), CD20 (+), bcl-2 (+), bcl-6 (+), CD10 (+), cyclin D1 (-), CD23 (-), c-myc (+, 100%).
      • Histology type: B-cell neoplasms; Diffuse large B-cell lymphoma
  • consultation
    • 2021-12-03 Cardiology
      • Q
        • The 69 y/o man recurrent lymphoma case, he has history of focal segmental glomerulosclerosis (UACR 783, Proteinuria 2+).
        • Due to SBP need keep < 130/80mmHg, his Exforge 5/160 1# bid, but can’t control, so we need your help for anti-hypertension drugs assassment. Thanks!
      • A
        • EKG showed NSR, LVH
        • Cardiac echo showed preserved LV function dilated LA Ao and LVH
        • please add doxaben 1 qd for BP control
        • If BP remained higher, indapamide 1 qd aslo can be administrated
    • 2021-12-02 Nephrology
      • Q
        • The 69 y/o man is a recurrent diffuse large B cell lymphoma case, he has past history of proteinuria and s/p biopsy at WanFang H (pathology report did not bring).
        • Due to urinalysis showed PRO 2+, so we need your help for management. Thanks!
      • A
        • Lab data:
          • U/A : clear yellow, SG: 1.013, PH: 5.5, Nit: -, Glu: -, Pro:2+, Ket :-, uro <1.5, Ob:- , RBC: 0-2, WBC: 0-5, bacteria:-
          • WBC: 5.9, Hb: 13.4, Plt: 176
          • BUN: 19,cre: 1.07, ALKP: 80, LDH: 194
          • Na: 140, K: 3.9, Albumin: 4.0, uric acid: 5.8
          • PE: edema-
          • Renal biopsy: FSGS (focal segmental glomerulosclerosis)
        • Impression:
          • Proteinuria caused by FSGS
        • Suggestion:
          • Check UACR
          • Keep Steroid 1mg/kg per day
          • DC ACEI
          • Esclate dose of ARB till BP control < 130/80mmHg
  • surgical operation
    • 2022-05-02
      • Surgery
        • Double lumen catheter insertion (RIJV approach, 16cm)
      • Finding
        • Adequate size of RIJV
      • Procedure
        • Under LA, supine, disinfection and well drapped.
        • Under sonography guidance, puncture into RIJV then wiring into RA
        • tunnel through RIJV puncture site, dilator insertion    
        • insert D/L
        • check flow, Hemostasis
        • secure the cath.  
    • 2021-11-08
      • Surgery
        • Excision of left neck lymph nodes      
      • Finding
        • Several enlarged lymph nodes at left neck level V, size around 1~2cm, two of them was removed for pathology pathology and TB culture/PCR
        • The spinal acccessory nerve was exposed at the operative field and well preserved
      • Procedure
        • The patient was in supine position with neck hyperextended and turned to the right side. Skin was disinfected and draped as usual. Local anesthesia with Bosmin-rinsed Xylocaine was injected into the subcutaneous tissue around the enlarged lymph noded after marked with the pen. A horizontal incision parallel to the skin crease was made. The subcutaneous tissue was cut through. Several enlarged lymph nodes at left neck level V, size around 1~2cm, two of them was bluntly dissected from its surrounding tissue and removed for pathology and TB culture/PCR. No obvious adhesion was noted. The spinal acccessory nerve was exposed at the operative field and well preserved. After hemostasis, the wound was closed with 2 layers. The patient tolerated the procedure well.  
    • 2017-08-18
      • Diagnosis
        • Lymphoma
      • PCS
        • 47080B
      • Finding
        • We identify the cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative C-arm to check its position.
      • Procedure
        • Under loca lanethesia, 3cm incision was made over R’t subclavicular region, outer 1/3. Superficial fascia was opened and the cephalic vein was found from upper border of the pectoralis major muscle. The cephalic vein was dissected and then pulled out with 3-0 silks over proximal and distal portions respectively. The lumen was opened by a scissor and the catheter was inserted into proximal lumen for 16 cm in length. The silks were tied so that the catheter was fixed in the proximal lumen and the distal end was ligated. After hemostasis and testing the function of the port-A, wound was closed layer by layer.
  • chemoimmunotherapy
    • 2022-04-19 - etoposide
    • 2021-12-08 ~ 2022-03-04 - R-DHAP (4 times)

==========

2022-07-19

  • Creatinine dropped to 1.8 mg/dL and BUN rose to 44 mg/dL, it would appear that there has not been a obvious decline in renal function and that some dehydration might possibly be present. (the latter is diarrhea caused?)
    • Creatinine
      • 2022-07-19 1.80 mg/dL
      • 2022-07-11 2.25 mg/dL
      • 2022-07-05 2.31 mg/dL
      • 2022-06-28 2.04 mg/dL
      • 2022-06-13 2.31 mg/dL
      • 2022-05-28 2.23 mg/dL
      • 2022-05-17 2.29 mg/dL
      • 2022-05-05 2.47 mg/dL
      • 2022-05-03 2.40 mg/dL
    • BUN
      • 2022-07-19 44 mg/dL
      • 2022-07-11 31 mg/dL
      • 2022-06-28 38 mg/dL
      • 2022-05-28 34 mg/dL
      • 2022-05-05 28 mg/dL
      • 2022-05-03 33 mg/dL
  • CrCl 35~40 mL/min, eGFR 38~45 mL/min/1.73m2, please check the following items in active prescription for patient’s clinical need
    • fluconazole
      • CrCl <=50 mL/minute: reduce normal dose by 50%.
    • levofloxacin
      • CrCl 20 to <50
        • If usual recommended dose is 500 mg every 24 hours: 500 mg initial dose, then 250 mg every 24 hours
        • If usual recommended dose is 750 mg every 24 hours: 750 mg every 48 hours
    • nystin
      • There are no dosage adjustments provided in the manufacturer’s labeling.
    • entecavir
      • CrCl 30 to <50 mL/minute: administer 50% of usual indication-specific dose daily. alternatively, administer the usual indication-specific dose every 48 hours.
    • pentoxifylline
      • CrCl >=30 mL/minute: there are no dosage adjustments provided in the manufacturer’s labeling. however, exposure to one of pentoxifylline’s the active metabolites (metabolite V) is increased with renal impairment; use with caution.
      • Aronoff 2007: CrCl 10-50 mL/minute: 400 mg every 12 to 24 hours

2022-07-12

[visiting]

  • I visited the patient at approximately 13:10 2022-07-12.
  • In spite of the upcoming transplant operation, the patient was still a bit nervous, which is believed to be a psychological reaction to the uncertainty of the future. In addition, he stated that he would actively cooperate with the doctor to receive treatment.
  • The patient was also concerned about whether or not the renal function will be maintained in the future. My explanation to him was that our medication are adjusted in accordance with his renal function.
  • No other medication-related questions raised by the patient.

2022-07-11

Dose adjustment recommendation for the scheduled PBSCT in this impaired renal function patient

  • The patient was diagnosed with stage III CKD on 2021-12-18 at Nephrology OPD.
  • The level of creatinine in his blood gradually increased between 2021Q4 and 2022Q1, and has remained slightly above 2 mg/dL since April 2022. Similar trends were observed in blood BUN.
  • 2022-07-11 creatinine 2.25 mg/dL -> eGFR 29.1 ~ 35.2 mL/min/1.73m2, CrCl 28.1 ~ 34.0 mL/min
  • As the patient has scheduled an autologous PBSCT for his NHL, let us go over the doses of items listed in the regimen:
    • BuCyE
      • busulfan
        • no dosage adjustments provided in the manufacturer’s labeling
      • cyclophosphamide
        • CrCl 10 to 29 mL/minute: administer 75% of normal dose
      • etoposide
        • CrCl 15 to 50 mL/minute: administer 75% of normal dose
    • premedication
      • phenytoin
        • primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine
        • no dosage adjustment necessary for any degree of kidney dysfunction
      • fluconazole
        • CrCl <= 50 mL/minute: reduce dose by 50%
      • levofloxacin
        • CrCl 20 to <50: if usual recommended dose is 500 mg every 24 hours, 500 mg initial dose, then 250 mg every 24 hours
      • palonosetron
        • no dosage adjustment is necessary.
      • granisetron
        • no dosage adjustment necessary
      • betamethasone
        • no dosage adjustments provided in the manufacturer’s labeling
      • mannitol
        • contraindicated in severe renal impairment. Use caution in patients with underlying renal disease.
  • The purchase order for busulfan has been sent and confirmed. In the event that a drug does not meet the schedule, the staff in the medicine storeroom will inform the updated status immediately.

701431525

220719

[assessment]

  • Cardinal Tien Hospital provided a diagnosis of “epigastric pain” on 2022-06-11. In addition to functional dyspepsia, if there are known cardiac risk factors, symptoms suggestive of angina (e.g., shortness of breath, exertional symptoms) might be evaluated.
  • This patient is admitted for bone marrow aspiration and biopsy.

700846672

220718

{T-cell lymphoma with bone invasion, stage IV}

  • past history
    • Pneumonia and meningitis in ShuangHo Hospital
    • Unknown neurology problem in ShuangHo Hospital
    • Depression
    • GERD
    • Lung benign nodule s/p OP
    • Viral hepatitis B
    • Chronic obstructive pulmonary disease
    • Polymyositis with respiratory involvement, anti-SAE1 and anti-MDA5 Antibodies positive
  • lab data
    • blood B2-Microglobulin (609-2366 ng/mL)
      • 2022-07-07 4691 ng/mL
      • 2022-06-11 2559 ng/mL
      • 2022-05-21 4000 ng/mL
      • 2022-04-02 3073 ng/mL
      • 2022-03-23 6077 ng/mL
      • 2022-02-21 2376 ng/mL
      • 2021-12-29 4427 ng/mL
    • Erythrocyte sedimentation rate, ESR (2-15 mm/hr)
      • 2021-12-28 55 mm/hr
      • 2021-09-27 72 mm/hr
      • 2021-09-08 56 mm/hr
      • 2021-09-02 60 mm/hr
      • 2021-04-05 38 mm/hr
      • 2021-01-25 42 mm/hr
      • 2021-01-05 34 mm/hr
      • 2020-12-09 55 mm/hr
  • exam finding
    • 2022-06-22 CXR
      • Patchy opacity projecting at right lower lung zone was noted. Please correlate with CT.
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening?
      • Enlargement of cardiac silhouette.
    • 2022-05-10 2D transthoracic echocardiography (prior to doxorubicin)
      • Normal AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size
    • 2022-04-16 KUB
      • Calcification in left pelvic cavity, could be due to granuloma.
      • Non-specific bowel gas pattern.
      • Clear margin of bilateral psoas muscles.
      • Lumbar spondylosis.
    • 2022-03-23 CT - abdomen, pelvis
      • Findings:
        • Prior CT identified lobulated soft tissue mass in RLL of the lung with calcifications component measuring 6 cm in the largest dimension is noted again, stable in size.
        • Fibrotic infiltrates in RUL of the lung show stationary.
        • Presence of small gallbladder stone.
        • Suspected liver cysts, up to 0.6cm in S4.
        • Tiny left renal stone.
        • There is no focal abnormality in the liver, biliary system, pancreas, spleen & right kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Prior CT identified lobulated soft tissue mass in RLL of the lung with calcifications component measuring 6 cm in the largest dimension is noted again, stable in size. please correlate with clinical condition.
    • 2021-12-07 CT - abdomen, pelvis
      • RLL tumor with right upper lung nodules, c/w lymphoma.
      • Lymph nodes in mediastinum and right hilar region, suspected lymphoma involvement.
      • GB stones.
      • RUL fibrotic infiltrates.
    • 2021-12-03 CXR
      • S/P port-A implantation.
      • S/P nasogastric tube insertion
      • S/P autosuture projecting at right upper lung.
      • Patchy opacity projecting at right lower lung zone was noted. Please correlate with CT.
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening?
    • 2021-12-02 Patho - bone marrow biopsy
      • Bone marrow, left buttock, biopsy — Positive for T-cell lymphoma
      • Microscopically, it shows bone marrow tissue with presence of aggregations and scattered T-cell type lymphomatous cells. The trilineage marrow components are not remarkable.
      • Immunohistochemical stain reveals CD3(+), CD20(-), CD136(< 5%), MPO(+), CD71(+), CD34(-) and CD117(-).
    • 2021-11-30 Whole body PET scan
      • A glucose hypermetabolic lesion in the posterior aspect of the lower lobe of right lung, compatible with lymphoma.
      • A glucose hypermetabolic lesion in the posterior aspect of the upper lobe of right lung and some glucose hypermetabolic lesions in the lower lobe of right lung and right pulmonary hilar region. Lymphoma should be watched out. Please correlate with other clinical findings for further evaluation.
      • Increased FDG uptake in the muslces in bilateral neck regions, proximal portions of bilateral upper arms, left anterior and posterior upper chest regions and bilateral lower pelvic regions. Physiological FDG uptake due to increased muscle tension or inflammation in these mucles may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2021-11-29 CXR
      • RLL mass consolidation
      • Reticulonodular opacities in in both lungs due to bronchiolitis
    • 2021-11-22 Patho - pleural/pericardial biopsy
      • Lung, RLL, CT-guide biopsy — malignant T-cell lymphoma
      • Sections show alveolar lung tissue with diffuse infiltration of small lymphocytes and interstitial fibrosis.
      • The immunohistochemical stains reveal CK(-), CD3(+), CD20(-), CD43(+), CD10(-), CD56(-), Cyclin D1(-). The number of CD8 positive lymphocytes is more than CD4 positive lymphocytes. The results are in favor of malignant T-cell lymphoma. Please correlate with the clinical presentation and lab study.
    • 2021-11-18 Electroencephalography, EEG
      • Findings
        • there are continuous slowing at 3-4 Hz bilaterally
        • photic stimulation showed no photo-driving response
        • hyperventilation study was not done
      • EEG classification: abnormal significance II, bilaterally continuous slowing, 3-4 Hz.
      • Interpretation: this EEG study showed moderate diffuse encephalopathy
    • 2021-11-16 CT - lung/mediastinum/pleura
      • Comparison made with previous CT dated on 2021/08/19
        • Lungs:
          • In comparison with the previous study on the lesion is increasing in size
          • further increase in size a large RLL mass-like consolidation with air bronxhograms containing coarse staple line and progression of lobular areas of consolidation and centrilobular nodular and branching opacities (especially in LLL) in both lungs of as compared with previous CT study on 20210819.
          • extensive centrilobular emphysema subpleural paraseptal emphysema
        • Mediastinum: no enlarged LN or mass. old calcified LN in Rt visceral space, sequela of previous TB infection
        • Hila: no enlarged LN.
        • Vessels: mild coronary arterial calcification.
        • Aorta: normal caliber, atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: small Rt effusion.
        • Chest walleck: unremarkable.
        • Visible abdominal contents: no abnormal density in visible portion of liver, spleen, adrenal glands, pancreas, and kidney.
        • Visualized bones: marginal spurs of vertebrae.
      • Impression:
        • progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 20210819.
    • 2021-08-19 CT - lung/mediastinum/pleura
      • Chest CT without IV contrast ehnancement shows:
        • Chest:
          • s/p right upper lobe and right lower lobe op. Soft tissue like change at right lower lobe section area is found. In comparison with CT dated on 2021-04-24, the lesion decresed in size.
          • Patent airway is found.
          • Some tree in bud appearance at residual right lung is found.
          • One new nodlar lesion at right lower lobe up to 0.88cm in largest dimension. Recent inflammation is favored but follow up is suggested.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
          • Suggest clinical correlation
      • Imp:
        • Post op. change of right upper lobe and right lower lobe
        • Tree in bud appearance at right lung, repeated inflammation is favored.
        • New nodular lesion at right lower lobe, suggest closely follow up.
    • 2021-07-24 CXR
      • Increased infiltration in right lung zone
      • Surgical stiches over right chest
      • Blunting of right CP angle
    • 2021-04-24 CT - lung/mediastinum/pleura
      • Chest CT without IV contrast ehnancement shows:
        • Chest:
          • s/p op. over right upper lobe and right lower lobe
          • Some fibrotic change and tree in bud appearance at right upper lobem, right lower lobe is found.
          • Calcified coronary arteries is found.
          • Dense calcified lymph nodes are found in the mediastinum.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
          • Suggest clinical correlation
      • Imp: post op. change at right upper lobe and right lower lobe
    • 2021-04-16 Abdominal Ultrasonography
      • Diagnosis
        • Fatty liver, mild
        • Liver cyst, small, S8
        • calcified spot of liver, S6
        • suspicious, GB stone
        • pancreatic tail masked by gas.
      • Suggestion
        • encourage exercise and diet adjustment.
    • 2020-12-30 Abdominal Ultrasonography
      • Diagnosis
        • Parenchymal liver disease, mild
        • Hepatic calcification, S6
        • Hepatic cyst, S4
        • GB polyp or stone (suboptimal study due to non-fasting status)
      • Suggestion
        • OPD follow-up
    • 2020-12-30 Brinchodilator Test
      • moderate restrictive impairment; non-significant bronchodilator response
    • 2020-10-21 MRI - brain
      • old insults in the bilateral basal ganglia.
    • 2020-10-20 MRI - c-spine
      • C3/4, C5/6 HIVDs.
      • No abnormal bony destruction.
      • No abnormal fluid collection.
  • consultation
    • 2021-11-26 Hemato-Oncology
      • Q
        • This is a 64 year-old male patient presented to our emergency department due to fever. He has the following past medical history:
            1. HBV
            1. Peptic ulcer
            1. depression
            1. Polymyositis with respiratory involvement, anti-SAE1 and anti-MDA5 Antibodies positive
            1. Pneumonia, with respiratory failure
            1. COPD(2020/11/25)
            1. recurrent pneumonia with respiratory failure s/p prior intubation months ago
        • Apart from mild grade fever, his family members reported that he has excessive sputum. Physical examination showed positive rhonchi and tachypnea. Laboratory data did not reveal leukocytosis but U/A with mild sign of urinary tract infection with mild elevated CRP(2.90). CXR showed RML pneumonia.
        • Under the impression of recurrent pneumonia and prerenal AKI (suspected dehydration induced), he is admitted to our ward for treatment.
        • According to the CT image revealed progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 2021/08/19. Arranged the CT guide biopsy, result malignant T-cell lymphoma. For maligant T-cell lymphoma, we are consulted.
      • A
        • Suggestion:
            1. Arrange PET for further work up
            1. Bone marrow aspiration and biopsy is indicated (suspected bone marrow involvement). We will discuss with patient and family.
            1. After image survey, Lumbar punture is indicated in this case. (suspected T cell lymphoma with CNS involvement). We will discuss with patient and family.
            1. Arrange 2D heart echo for future anthracycline base chemotherapy
            1. please complete baseline LDH, uric acid. (watch for tumor lysis after chmoetherapy), moreover, please check HbsAg, Anti-Hbs,Anti-Hbc, Anti-HCV
            1. Thanks for your consultation, we wound take over this case if you agree.
    • 2021-11-17 Radiation Oncology
      • Q
        • This time, we arranged the chest CT result progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 2021/08/19. OPD medicines (Plavix) was hold since 2021/11/17 for prepare CT guide biopsy. We need your expertise and evaluate. Thanks!
      • A
        • This 64-year-old male patient is a case of RLL lung mass, suspected malignancy. CT-guided biopsy is indicated. Please check platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
    • 2021-11-16 Neurology
      • Q
        • Family complaint the patient conscious drowsy since 2021/11/14. We need your expertise and evaluate. Thanks!
      • A
        • O
          • Consciousness: GCS E3V1M5
          • Cranial nerve: pupil 2+/2+, VF intact, EOM: move freely; no facial palsy, on NG
          • Motor: >3/>3
          • sensory of limbs: symmetric
          • Chest CT: progressive increase in size a large RLL mass-like consolidation and bilateral lung infection (especially in LLL) as compared with previous CT study on 2021/08/19.
          • Lab: Cr: 0.86 => 3.42, CRP: 2.9
        • Impression:
          • Conscious disturbance due to infection, AKI and respiratory failure
          • Polymyositis with respiratory involvement, anti-SAE1 and anti-MDA5 Antibodies
        • Suggestion:
          • Please check CPK, Ca, Mg, P, TSH, Free T3, T4, Anti TPO and anti thyroglobulin Ab, 8AM Cortisol, ACTH, B12, Folic acid.
          • Arrange EEG
    • 2021-07-02 Infectious Disease
      • Q
        • This is a 63 year old man who was admitted to our hospital because of fever and dyspnea for several days. The patient had underlying polymyisitis, COPD and old CVA on regular OPD follow up at our hospital. Several days prior to admission to our hospital, the patient developed fever and dyspnea. He denied having diarrhea, change in the sense of smell or taste. On 2021/06/27, the patient was brought to our ER to seek medical attention.
        • Blood test showed elevated levels of CRP, lactate and WBC, while CXR revealed ground glass opacities in both lungs. Sputum culture on 2021/06/30 showed CRAP. In the following days, his fever off and on wihtout regression under the treatemtns of brosym.
        • Cr: 2.56 mg/dL
      • A
          1. Zavicefat for CRPA is indicated.
          1. Agree with your use of colimycin inhalation.
    • 2021-06-28 Infectious Disease
      • Q
        • Blood test showed elevated levels of CRP, lactate and WBC, while CXR revealed ground glass opacities in both lungs.
      • A
        • Antibiotics with brosym and cravit is suggested.
    • 2021-01-05 Rehabilitation
      • Q
        • In addition to unable to stand, we sincerely ask for your expert and ambulation training.
      • A
        • Premorbid status
          • Walk and BADL ID
        • Physical examination
          • Consciousness: E4V5M6
          • Cognition: mostly intact
          • Speech: mostly intact
          • Swallowing: oral feeding
          • Sphincter: continence
          • MP: UE: 5/5; hip and knee: 3/3; ankle: 0/0
          • Functional status: bed mobility under min A
          • BADL: feeding, grooming ID; others under mod-max A
        • Assessment
          • polymyositis with respiratory involvement with positive anti-SAE1 and anti-MDA5 antibodies
          • depression
          • GERD
          • COPD
        • Plan
          • Rehabilitation programs: Bedside PT rehabilitation programs
          • Goal: improve lower extrimities endurance and muscle strength, improve transfer skills
          • Prescribe bilateral posterior AFO for him to prevent ankle contracture
    • 2020-10-23 Rehabilitation
      • Q: We need your help for arrange rehabilitation. Thank a lot!
      • A
        • 2020-10-01 NCV
          • mixed type sensorimotor polyneuropathy with bilateral lower cervical and lumbosacral radiculopathy.
        • Premorbid status
          • Unknown
        • Physical examination
          • Consciousness: E4VTM6
          • Cognition: could follow orders
          • Speech: tracheostomy
          • Swallowing: NG (+)
          • Sphincter: Foley (+), stool in diaper
          • MP: UE: 4/4, LE:2/2
          • Functional status: bed rest
          • BADL: needs max assistance
        • Assessment
          • generalized weakness especially at LEs, with difficulty weaning, suspect uncertain GBS (AMSAN), paraneoplastic polyneuropathy, critical illness polyneuropathy, inherited polyneuropathy, CIDP, MG
          • depression
          • Peptic ulcer
          • benign right lung nodule
        • Plans
          • Rehabilitation programs: Bedside PT rehabilitation programs
          • Goal: recondition, improve endurance and muscle strength
    • 2020-10-16 Rheumatology and Immunology
      • Q
        • This 63 year old man had
            1. Pneumonia over bilateral (2020/09/03 Sp/C: CRPA)
            1. IHCA s/p CPCR s/p ET s/p extubation on 2020/09/11. Re-intubation on 2020/09/15; s/p Tr. on 2020/10/12
            1. Pulmonary TB s/p anti-TB agent since 2020/08/06
            1. Lower limbs weakness; suspected ALS or MG
        • 2020/10/02 Neurologist: generalized weakness with difficulty weaning, suspect uncertain GBS (AMSAN), paraneoplastic polyneuropathy, critical illness polyneuropathy, inherited polyneuropathy, CIDP, MG, Check autoantibodies SAE1 positive and MDA5 positive. He accepted pulse therapy medason 80mg Q8H*2day 2020/10/16-17. (Medason - methylprednisolone sodium succinate buffered 3%)
        • Due to Antibody-positive (SAE1) and anti-MDA5 antibodies positive consult evaluation. Thank you.
      • A
        • History review & physical examination were performed. Due to positive MDA5 & pulmonary fibrosis, inflammatory myopathy can’t be ruled out.
        • Suggestion:
            1. Treatment as current your expert’s management.
            1. Please check muscle enzyme, arrange EMG if no contraindication.
            1. Consider immunotherapy if no infectious contraindication.
            1. Please inform me again if there are any informative reports.
    • 2020-10-10 Anesthesiology
      • Q
        • for anesthesi evaluation
        • Hx: Depression, GERD
        • This is a 63 year-old male was admitted for impression of Pneumonia. Due to difficulted weaning of ventilator, CS was consulted and arrange tracheostomy on 2020/10/12 on call. We need your help for anesthesia evaluation.
      • A
        • Current problem:
            1. respiratory failure s/p ETT intubation, failure to weaning
            1. TB s/p medication use
            1. depression/ GERD
        • Plan:
            1. ASA: III
            1. Arrange GA with current ETT`
            1. please treat the patient’s current respiratory infection and TB under your expertise
            1. post-op ICU care
            1. inform the patient’s daughter about increasing risk of desaturation, hypotension, shock and bleeding during surgery
    • 2020-10-10 Thoracic Surgery
      • Q
        • In our hospital, PE showed right lung crackle sound. Lab data showed WBC 28140 with neutrophil 92%. Influenza screen was negative. CXR showed conslidation in the right lung field and mild blunting of right costophrenic angle. Under the impression of pneumonia with TB suspected, he is admitted for treatment and further evaluation.
        • After admission, he was treated with Brosym and TB medicins. Desaturation was noted on 2020/09/01, we changed the nasal canula to simple mask and saturation back to 94%. Blood culture was done too. CXR on 20200901 showed pneumonia progression, so we added Targocid. Sputum culture was collected on 20200902. Diamox (acetazolamide) 1# TID was added for 2 days on 20200902 due to metabolic akalosis. On 20200903 midnight, loss of consciousness with dyspnea was noted. Hypercapnic respiratory failure and septic shock was impressed. Assystole also occured, s/p CPCR for 1 min. Intubation was also done. And he was transfer to ICU for further care.
        • After transferred to ICU, he received inotropic agents, anti-TB agent with Akurit4 plus vit B6 since 20200806. However, fever developed was happened, discontinued Targocid (20200903~0910) and Mepem (20200903~0907), ex-change to Fortum (0907-0913) plus Colimycin IV(0907-0914) for sputum culture revealed CRPA. Adequate IV fluid for polyuria and albumin transfusion for hypoalbuminemia. Episode of persisted fever was also note and still S/C yiled CRPA, ex-change antibiotic to Mepem since 0913 was prescribed. Ventilator weaning then extubation on 20200911 under Mask full supply. But, weakness of cough reflex and elevation breathing work and desaturation were also note, re-intubation on 20200915 with ventilator supply. IV Colimycin since 20200916 was added for fever and S/C yiled CRPA, shifted to INHL on 20200922. Lower limbs weakness consider HIVD relate. Added Plavix for old CVA. RCC was consculted due to ventilator difficlut weaning and bedside rehabilitation, but hold scheduled due to fever and hematuria.
        • Arrange lower NCV study for persist lower limbes weakness,that report showed mixed type sensorimotor polyneuropathy with bilateral lower cervical and lumbosacral radiculopathy.
        • For difficult weaning ventilator ,so we need your help for tracheostomy evaluation. Thanks!
      • A
        • I will arrange tracheostomy for this patient after explained about risk and benefit next Monday. Thanks for your consultaiton.
    • 2020-10-02 Neurology
      • A
        • S
          • For persisted lower limb waeaknss and difficulty weaning, we were consulted for further evaluation.
          • According to the statment of his family, he complained of right chest/axillary pain (stabbing, intermittent with progressing frequency and intensity) over 10+ years. Before he was admited to ShuangHo Hospital this July, he complained of distal numbness with pain for a while. His wife mentioned of easily awakenend during sleep with limbs movment for 30 years, profuse sweating upon movmenet for many years were also menetioned. Weight loss about 20 kg within a year, with decreased appetite and altered taste. Denied urine retention, changed urine color, costipation, tachycardia, choking, dysarthria, tremor or other involuntary movements, travel or contact history.
          • From ShuangHo Hospital medical records, polyneuropathy was impressed with EMG myopathic findings. In addition, porphyria was highly suspected from positive finding in screening test and the result should be persuit.
          • 2020-10-01 NCV: mixed type sensorimotor polyneuropathy with bilateral lower cervical and lumbosacral radiculopathy.
        • O
          • Personal Hx:
            • denied toxic exposure history (contacted with acetone 20 years ago),
            • smoking (+, 1 PPD for 40 years)
            • alcohol 3-4 times per week/beer*10 bot, quit recently
            • denied family hx
          • NE: E4VTM6, cachexia, could answer by hand writing and gesture
          • EOM: free, no limitations
          • Nuchal rigidity : + (?)
          • CNS: noraml light reflex, symmetry CN5 sensations, normal pursuit and saccade, nystagmus (-), diplopia (-, intermittent as the patient stated)
          • Msucle atrophy and wasting
          • tone: soft and symmetric
          • power:
            • UE R/L: 3-4
            • LE R/L: Prox3Dis2/Prox3Dis2
          • DTR:
            • UE R/L: 2+/2+
            • LE R/L: -/-
          • Babinski: no response/no response
          • Sensation: bilateral lower limbs decreased with allodynia (?)
        • Impression: generalized weakness with difficulty weaning, suspect uncertain GBS (AMSAN), paraneoplastic polyneuropathy, critical illness polyneuropathy, inherited polyneuropathy, CIDP, MG
        • Suggestion:
          • check ACHR antibody to rule out MG and check Fabry disease serum check-up
          • persuit porphyria result
          • consider to repeat CSF study including self-paid exam including paraneoplastic autoantibiodies (the fee was about NT 30000)
          • consider to repeat tumor marker survey if CSF study repeated
          • Contact us if any questions and thank you for consultation.
    • 2020-09-24 Gastroenterology
      • A
        • Treat pneumonia
        • Survey the etiology elevated CA125 in “Male” patient (?)
        • Elective panendoscopy and colonoscopy after transfer to general ward under stable condition
    • 2020-09-18 Thoracic Medicine
      • Q
        • This time, due to ventilator diffcilut weaning, need your evaluation ventilator traning, thanks a lot!
      • A
        • After transfer to ICU, he received inotropic agents, antiTB agent with Akurit4 plus vit B6 since 20200806. However, fever developed, antibiotic with Targocid (teicoplanin) 9/3~9/10 and Mepem (meropenem) 9/3~9/7 shift to Fortum (ceftazidime) + colimcyin IV form (9/7~)for sputum culture revealed CRPA, blood transfusion for anemia. adequate IV fluid for polyuria and albumin transfusion for hypoalbuminemia. Ventilator weaning then extubation on 2020/09/11 under Mask full supply. But, weakness of cough reflex and elevation breathing work and desaturation were also note, re-intubation on 2020/09/15 with ventilator supply.
        • Transfer to RCC next week if bed available
    • 2020-09-03 Infectious Disease
      • Q
        • A 64 y/o male under the diagnosis of progressing pneumonia with septic shock + ARDS s/p ETT +MV and CPCR for 1 min despite under Targocid + Brosym. Long term hospitalization(transfered from ShuangHo Hospital), VAP first considered, but atypical pneumonia is also considered due to prolong disease course. Mepem + Cravit for septic shock and atypical coverage, thank you!
      • A
        • Consultation for Mepem antibiotic.
        • S/O
          • A 63-yeara-old suspect pulmonary TB male patient has severe both-lung pneumonia with pneumonia progression despite Brosym and anti-TB medications.
          • Persistent fever is noted during hospitalization, followed by respiratory failure and severe sepsis.
          • White count up to 29130 this early morning, with high CRP level 29.46 and hyperlactatemia.
          • Sputum culture shows normal flora only.
          • Brosym is replaced by Mepem, Cravit, and Targocid now.
        • Suggestion:
            1. Continue the present antibiotic regimen for one week first.
            1. Send sputum for TB-PCR and check serum fungal Aspergillus and Cryptococcal antigen titer.
  • chemoimmunotherapy
    • 2022-05-10 ~ undergoing - CHOP (cylcophosphamide + doxorubicin + vincristine + prednisolone)
    • 2021-12-06 ~ 2022-03-22 - COP (cylcophosphamide + vincristine + prednisolone)
    • 2021-09-27 - Rituximab

[note]

  • The disease should be subtype Peripheral T-cell lymphoma (PTCL), not otherwise specified (NOS)?

  • T-Cell Lymphomas NCCN EB Version 2.2022 - March 7, 2022, p13

    • For PTCL-NOS histologies, preferred regimens (alphabetical order)
      • Brentuximab vedotin + CHP (cyclophosphamide, doxorubicin, and prednisone) for CD30+ histologies
      • CHOEP (cyclophosphamide, doxorubicin, vincristine, etoposide, prednisone)
      • CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)
      • Dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin)
  • Restage after 3-4 cycles with PET/CT (preferred) or C/A/P CT scan with contrast

  • Recommended Adult Immunization Schedule — United States, 2012 ( https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm )

    • Pneumococcal polysaccharide (PPSV) vaccination
      • Vaccinate all persons with the following indications:
        • age 65 years and older without a history of PPSV vaccination;
        • adults younger than 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]);
        • residents of nursing homes or long-term care facilities; and
        • adults who smoke cigarettes.
      • Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis.
      • When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks. Vaccination during chemotherapy or radiation therapy should be avoided.

==========

2022-07-18

[to be discussed]

[assessment]

  • Nexium (esomeprazole) must not be ground. Please open the capsure and pouring out the small granules and dissolved them in adequate drinking water prior to tube feeding.

2022-06-02

  • The pathology reports (2021-11-22, 2021-12-02) did not specify CD30, ALK (anaplastic lymphoma kinase) or ALCL (anaplastic large cell lymphoma) subtype information.
  • If CD30 is confirmed positive, brentuximab vedotin may prove beneficial.
  • Past history of polymyositis has been linked to an increased incidence of cancer. reference:
  • Low HGB level (8.7 g/dL 2022-06-01) combined with underlying COPD might limit ventilation and/or oxygenation, please be aware of low oxygen symptoms.

701150775

220714

{pancreatic neck adenocarcinoma,cT1cNXM1, stageIV, with retroperitoneal spread status post Roux-en-Y hepatico-jejunostomy and cholecystectomy}

[objective]

  • exam findings
    • 2022-03-30 CT - abdomen, pelvis
      • pancreatic neck cancer with vessel encasement and lymph nodes metastases show mild decreasing in size.
    • 2022-01-26 CT - abdomen, pelvis
      • pancreatic neck cancer with vessel encasement, lymph nodes metastases, and lung metastases.
    • 2022-01-06 Patho - F2022-00006
      • soft tissue, retroperitoneal, biopsy - metastatic adenocarcinoma, consistent with pancreas origin
      • section shows fibroadipose tissue and nerve bundles with metastatic adenocarcinoma. perineural invasion is seen.
      • IHC: CK7(+), CK20(-), and CK19(+).
      • the morphology and immunohistochemical stains are consistent with pancreas origin.
    • 2021-12-14 Patho -
    • 2021-12-03 Endoscopic Ultrasonography, EUS
      • pancreatic genu tumor s/p CH-EUS & EUS/FNB
      • lymphadenopathy, beside hepatic hilum
      • reflux esophagitis LA classification grade A
    • 2021-12-02 Ultrasound - abdomen
      • pancreastic head tumor with lymphadenopathy
      • GB sludge with distension
      • CBD dilatation
      • fatty liver, mild
    • 2021-11-30 MRI - pancreas
      • a faint enhancing tumor (1.2cm) at pancreatic body with distal p-duct dilatation.
      • some LNs around celiac trunk and proximal SMA.
      • dilatation of biliary tree suspected distal CBD lesion.
      • inhomogeneous intensity of pancreatic head.
    • 2021-11-25 CT - abdomen, pelvis
      • suspected pancreatic body cancer with distal pancreatic duct dilatation.
      • T4N1M0
  • chemotherapy
    • 2022-01 ~ ongoing: FOLFIRINOX
      • FOL: folinic acid (leucovorin), a vitamin B derivative that enhances the effects of 5-fluorouracil (5-FU);
      • F: fluorouracil, a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops DNA synthesis;
      • IRIN: irinotecan, a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating; and
      • OX: oxaliplatin, a platinum-based antineoplastic agent, which inhibits DNA repair and/or DNA synthesis.

==========

2022-07-14

  • ALT (2022-07-13) was 117 U/L, the dose of irinotecan has been reduced to 150 mg/m2.

2022-04-20

  • FOLFIRINOX is a chemotherapy regimen that is used to treat advanced pancreatic cancer. The patient is undergoing the regimen since Jan 2022.
  • 2022-03-30 updated CT images showed a mild decrease in the size of the tumor, indicating that current treatment is working. However, CA-199 (137U/mL 2022-04-06) remained above the upper limit of normal, and should be noted.
  • S-GPT/ALT elevated since late March (126U/L 2022-04-19), if bilirubin also elevates up to 1.5mg/dL, then the dosage of irinotecan should be lowered.
  • Some targeted therapeutic agents might be an option if no contraindication
    • pembrolizumab for MSI-H or dMMR cases.
    • larotrectinib/entrectinib for NTRK gene fusion positive cases.

2022-02-15

  • FOLFIRINOX is a chemotherapy regimen for treatment of advanced pancreatic cancer. the patient is on this regemen, which is made up of the following four drugs:
    • FOL: folinic acid (leucovorin), a vitamin B derivative that enhances the effects of 5-fluorouracil (5-FU);
    • F: fluorouracil, a pyrimidine analog and antimetabolite which incorporates into the DNA molecule and stops DNA synthesis;
    • IRIN: irinotecan, a topoisomerase inhibitor, which prevents DNA from uncoiling and duplicating; and
    • OX: oxaliplatin, a platinum-based antineoplastic agent, which inhibits DNA repair and/or DNA synthesis.
  • some targeted therapeutic agents might be considered if no contraindication
    • pembrolizumab for MSI-H or dMMR cases.
    • larotrectinib/entrectinib for NTRK gene fusion positive cases.

701374548

220714

{DLBCL}

  • lab data
    • 2022-05-24 HBsAg(核醫) Negative
    • 2022-05-24 HBsAg Value(核醫) 0.399
    • 2022-05-23 Anti-HBs 0.14 mIU/mL
    • 2022-05-23 Anti-HBc Nonreactive
    • 2022-05-23 Anti-HBc-Value 0.15 S/CO
    • 2022-05-23 Anti-HCV Nonreactive
    • 2022-05-23 Anti-HCV Value 0.06 S/CO
  • exam finding
    • 2022-06-21 2D transthoracic echocardiography
        1. Normal LV systolic function with normal wall motion.
        1. Normal LV diastolic function.
        1. Normal RV systolic function.
        1. Typical mitral valve prolapse (bileaflet) with trivial MR; mild TR.
    • 2022-05-26 Whole body PET scan
        1. Glucose hypermetabolism in the right inferior buccal region, compatible with diffuse large B-cell lymphoma.
        1. Increased FDG accumulation in bilateral kidneys, probably physiological uptake of FDG.
        1. Diffuse large B-cell lymphoma, stage I (AJCC, 8th ed.), by this F-18 FDG PET scan.
    • 2022-05-24 Patho - bone marrow biopsy
      • Bone marrow, biopsy — No evidence of lymphoma involvement
      • The sections show normocellular marrow (35%). M/E ratio = 5:1. The myeloid cells show good maturation with mild neutrophilia. The megakaryocytes are normal in number and morphology. The erythoid precursors are not remarkable.
      • IHC, scattered small CD3+ T-cells and CD20+ B lymphocytes in interstitium and no lymphoid aggregates can be found. There is no evidence of lymphoma involvment in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2022-05-18 Patho - salivary gland biopsy
      • pathologic diagnosis
          1. Tumor, R’t buccal mucosa, excision — Diffuse large B-cell lymphoma
          1. Residual tumor, ditto — Diffuse large B-cell lymphoma and reactive lymph nodes
      • microscopic examination
        • Main tumor: diffuse large B-cell lymphoma shows medium to large atypical lymphoid cells with mitoses and occasional nucleoli.
          • Immunohistochemistry shows CD3(-), CD20(+), cyclin-D1(+, focal ), Bcl-2(+), CK(-), CD10(-), Bcl-6(+), C-MYC(-) and Ki-67: 80% for tumor.
          • According to all above histopathologic findings, it indicates a case of diffuse large B-cell lymphoma.
        • Residual tumor: one node showed diffuse large B-cell lymphoma as well as two reactive lymph nodes.
    • 2022-05-17 MRI - nasopharynx
      • Clinical information: suspected adenoma of right mandible.
      • Findings:
          1. One well-defined mass lesion (5.0cm in length) over right mandibular space, showing high-signal intensity on T2WI and homogeneous enhancement. Favor a soft tissue lesion. Suggest tissue proof.
          1. Normal appearance of both mastoid air-cells.
          1. Clear appearacne of all paranasal sinuses.
    • 2022-05-16 ECG
      • Normal sinus rhythm
      • Possible left atrial enlargement
    • 2022-05-16 CxR
      • No cardiomegaly
      • No active lung lesion
      • Normal bony contour
  • consultation
    • 2022-05-23 Hemato-Oncology
      • Q
        • For evaluation and further management of diffuse large B-cell lymphoma
        • This is a 40-year-old female suffering from a painless mass over right lower face and was admitted on 2022/05/16 for surgical management.
        • According to her statement, she noted a painless mass at her right lower face about 6 months and the tumor was growing rapidly within past few months, she came to our OS OPD for help on 2022/04/26. Physical examination showed a mobile, painless lump at the right buccal-retromolar area, about 3.5 cm in size. No sensory change or numbness was complained by the patient. Under the impression of adenoma of right mandible, she underwent excision of oral tumor under general anesthesia on 2022/05/18. Post-operatively, mild sensory disturbance over right chin was reported by the patient. However, the pathological report showed diffuse large B-cell lymphoma of right mandible. Thus, we need your expertise for further evaluation and management. Thanks for your time.
      • A
        • Impression:
          • right buccal diffuse large B-cell lymphoma
        • Suggestion:
            1. Arrange PET scan for staging and port A insertion
            1. Please check HbsAg, Anti-Hbc, Anti-HCV, LDH
            1. We will arrange bone marros aspiration and biopsy on 2022/05/24
            1. After above was done, please arrange our hematology OPD
            1. Thanks for your consultation.
  • chemoimmunotherapy
    • 2022-06-22 ~ undergoing - R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)

[assessment]

  • DLBCL stage I, PS 0, IPI score 0; lab data on 2022-07-13 and TPR, BP, SpO2 during this hospitalization were generally normal.
  • R-CHOP treatment has been provided to the patient since 2022-06-22 without any known issue.

701359667

220708

{Endometrium neuroendocrine carcinoma, pT2pN0M0, FIGO stage II s/p Staging surgery(ATH + BSO + omentectomy + LN dissection) on 2022/02/14}

[objective]

  • exam finding
    • 2022-05-26 CT - abdomen, pelvis
      • Findings:
        • S/P hysterectomy.
        • Left renal stone (3mm).
        • Atherosclerosis of aorta, iliac arteries.
      • IMP:
        • S/P hysterectomy.
        • No evidence of tumor recurrence.
    • 2022-03-07 Pure tone audiometry, PTA
      • Reliability FAIR
      • Average RE 43 dB HL; LE 111 dB HL.
      • R’t mild to moderately severe SNHL.
      • L’t moderately severe to profound mixed type HL.
    • 2022-02-14 Patho - uterus with or without SO non-neoplastic/prolapse
      • PATHOLOGIC DIAGNOSIS
        • Uterus, endometrium, total hysterectomy — Neuroendocrine carcinoma.
        • Uterus, myometrium, total hysterectomy — Neuroendocrine carcinoma. Invading > 1/2 thickness of the myometrium and 0.4 cm from serosal surface.
        • Uterus, cervix, total hysterectomy — Neuroendocrine carcinoma. Invading endocervix.
        • Ovaries and fallopian tubes, bilateral, BSO — Free
        • Lymph node, bilateral pelvic and para-aortic, dissection — Free
        • pT2 pN0 (if cM0) AJCC 8th edition Pathology FIGO stage: II, at least.
      • MACROSCOPIC EXAMINATION
        • Operation Procedure: Staging surgery(ATH + BSO + omentectomy + LN dissection)
        • Specimens include: uterus, bilateral adnexae, bilateral pelvic and para-aortic lymph nodes.
      • MICROSCOPIC EXAMINATION
        • Histology type: Large cell neuroendocrine carcinoma
        • Histology grade: high grade.
        • Depth of invasion: invade > 1/2 thickness of the myometrial wall
        • Uterine Serosa Involvement - Not identified
        • Cervical Stromal Involvement - Present
        • Other Tissue/ Organ Involvement - Not identified
        • Bilateral, ovary: free
        • Bilateral, fallopian tube: free
        • Omentum: free
        • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
          • Ectocervical/Vaginal Cuff Margin: Free 2.5 cm away
      • Parametrial/Paracervical Margin: Free
        • Lymphovascular Invasion: Present
        • Regional Lymph Nodes: free
        • Ancillary Studies - S2022-02021: IHC stains: CD56 (+), Ki-67: 30-40%, p40 (-), WT-1 (-), vimentin (focal +), p16: <70%.
    • 2022-02-11 Whole body PET scan
      • A prominent glucose hypermetabolic lesion in the uterus, compatible with primary endometrial malignancy.
      • A small focal area of mildly increased FDG uptake in the right lateral aspect of the pelvic cavity. The nature is to be determined (a metastatic lymph node of low FDG uptake? other nature such as inflammation?). Please correlate with other imaging modalities for further evaluation.
      • Increased FDG accumulation in both kidneys, right ureter and intestine. Physiological FDG accumulation is more likely.
    • 2022-02-09 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C — Neuroendocrine carcinoma.
      • IHC stains: CD56 (+), Ki-67: 30-40%, p40 (-), WT-1 (-), vimentin (focal +), p16: <70%.
      • Section show(s) piece(s) of markedly necrotic tissue with infiltration of sheets, nests, and trabeculae of round blue neoplastic cells demonstrating pleomorphic nuceli.
    • 2022-02-07 MRI - pelvis
      • Suspected endometrial malignancy, cstage T1bN2M0. IIIc.
      • Uterine myoma, in cervical region.
    • 2022-02-04 Gynecologic ultrasonography
      • Endometrial thickening (EM:43.8mm)
      • Uterine myoma
  • lab data
    • 2022-02-26 Chromogranin A 52.1 ng/mL
    • 2022-02-24
      • Anti-HBs 9.49 mIU/mL
      • Anti-HBc Reactive
      • Anti-HBc-Value 4.50 S/CO
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.02 S/CO
      • HBsAg Nonreactive
      • HBsAg (Value) 0.35 S/CO
    • 2022-02-13
      • Blood type ABO B
      • RH(D) Positive
  • surgical operation
    • 2022-02-14
      • Surgery
        • Diagnosis: endometrial malignancy, staging surgery. suspected endometrial malignancy, cstage T1bN2M0. III
        • Operation: Staging surgery (ATH + BSO + omentectomy + LN dissection)     - Finding
        • Supraumbilical midline vertical skin incision
        • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied.
        • Adnexa:
          • LOV: 3x2x2cm, grossly normal
          • ROV: 2x2x2cm, grossly normal
          • Fallopian tube: bilateral grossly normal
          • CDS: mild adhesion
          • Ascites: 10 ml
          • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(+, right para aortic area)
          • Omentum: grossly normal
          • Liver: grossly normal and smooth
          • Appendix: not seen
          • After the operation, optimal debulking surgery was achieved.
          • Residue tumor: R0, No residual tissued left as we seen.
          • Estimated blood loss: 400ml
          • Blood transfusion: nil
          • Complication: nil
    • 2022-02-09
      • Surgery
        • Diagnosis: MRI reported suspect EM malignancy, cstage T1bN2M0
        • Operation: Diagnostic dilatation and curettage for pathology     - Finding
        • Uterus: anteversion/retroversion, sounding: 8 cm, dilatation to Hegar No. 9.
        • Some endometrial tissus was curetted from endometrial cavity.
        • Estimated blood loss: 3 ml , Blood transfusion: nil, Complication: nil.
  • Radiotherapy
    • 2022-03-18 ~ - 4500cGy/25 fractions of the pelvic area.
  • Chemoimmunotherapy
    • 2022-03-09 ~ undergoing - etoposide + cisplatin

==========

2022-05-03

  • Estrogen receptor (ER) testing is recommended in the settings of stage III, stage IV, and recurrent disease.
  • HER2 immunohistochemistry (IHC) testing is recommended for possible treatment of advanced-stage or recurrent serous endometrial carcinoma or carcinosarcoma.
  • Consider HER2 IHC testing in TP53-aberrant endometrial carcinoma regarless of histotyping.
  • Molecular analysis of endometrial carcinoma has identified four clinically significant molecular subgroups with differing clinical prognoses: POLE mutations, microsatellite instability-high (MSI-H), copy number low, and copy number high.
  • Ancillary studies for POLE mutations, mismatch repair (MMR)/MSI, and aberrant p53 expression are encouraged to complement morphologic assessment of histologic tumor type.
  • Universal testing of endometrial carcinomas for MMR proteins is recommended (MSI testing if results equivocal).
  • Consider NTRK gene fusion testing for metastatic or recurrent endometrial carcinoma.

700900252

220701

{Pancreatic adenocarcinoma, T4N1M0, stageIII}

  • lab data
    • Glucose (serum)
      • 2022-06-30 218 mg/dL
      • 2022-06-04 172 mg/dL
      • 2022-05-31 279 mg/dL
      • 2022-03-25 120 mg/dL
      • 2022-01-21 126 mg/dL
      • 2021-11-25 112 mg/dL
      • 2020-08-21 113 mg/dL
      • 2020-08-06 115 mg/dL
    • Mg (Magnesium) (1.9~2.7)
      • 2022-06-30 1.3 mg/dL
      • 2022-06-21 1.8 mg/dL
      • 2022-06-17 1.8 mg/dL
      • 2022-06-11 1.2 mg/dL
      • 2022-06-09 2.7 mg/dL
      • 2022-06-07 1.3 mg/dL
      • 2022-05-31 1.6 mg/dL
      • 2022-05-24 1.6 mg/dL
      • 2022-04-07 2.1 mg/dL
      • 2022-01-24 1.9 mg/dL
    • Albumin
      • 2022-06-30 3.2 g/dL
      • 2022-06-21 2.6 g/dL
      • 2022-06-17 2.5 g/dL
      • 2022-06-11 2.5 g/dL
      • 2022-06-07 2.6 g/dL
      • 2022-05-31 3.5 g/dL
      • 2022-05-24 3.3 g/dL
      • 2022-05-12 3.3 g/dL
      • 2022-04-28 4.3 g/dL
      • 2022-04-25 4.1 g/dL
      • 2022-04-19 3.5 g/dL
      • 2022-04-14 4.0 g/dL
      • 2022-04-07 3.7 g/dL
      • 2022-03-26 3.9 g/dL
      • 2022-01-24 3.2 g/dL
  • exam finding
    • 2022-06-20 2D transthoracic echocardiography, TTE
      • Findings
        • Heart size: Dilated LA, AsAo (35 mm); (LA volume: 65 ml, LA volume index: 50 ml/m2)
        • Mitral E/A = 83 / 115 cm/s (E/A ratio = 0.72); Dec.time = 174 ms; Heart rate = 94 bpm
        • Septal MA e’/a’ = 5.4 / 12.2 cm/s; Septal E/e’ = 15.5 ;
        • Lateral MA e’/a’ = 8.8 / 18.4 cm/s; Lateral E/e’ = 9.5 ;
        • Calcified lestions: aortic root
        • IVC size 13 mm with inspiratory collapse >50%
      • Conclusion:
        • Indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
        • Normal LV and RV systolic function.
        • Mild aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
        • Dilated proximal ascending aorta (35mm); prominent aortic root calcification with protruding atheroma (7.5 mm of thickness).
        • No vegetation was found by TTE study.
    • 2022-06-15 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
    • 2022-06-13 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 36 dB HL // LE 36 dB HL
      • RE normal to moderately severe SNHL (sensorineural hearing loss)
      • LE normal to moderate SNHL (sensorineural hearing loss)
    • 2022-06-04 CXR
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-06-04 KUB
      • Degenerative joint disease of lumbar spine with marginal osteophytes.
    • 2022-06-04 ECG
      • Sinus tachycardia
    • 2022-05-09 Cholangiography
      • Cholangiography via PTCD catheter administration revealed:
        • S/P cholecystojejunostomy.
        • Obstruction of distal CBD.
        • Patency of the catheter.
    • 2022-04-19 Patho - pancreas biopsy
      • Diagnosis
        • Pancreas, biopsy — chronic inflammation and fibrosis
        • F2022-00175
          • FsA: Soft tissue, SMA root, biopsy — negative for malignancy
          • FsB: Pancreas, biopsy — chronic inflammation and fibrosis
            • Lymph node, site?, excision — metastatic adenocarcinoma (1/1)
      • Microscopic description
        • Section shows pancreatic tissue with infiltration of chronic inflammatory cell and fibrosis. No invasive tumor is found. The immunohistochemical stain of CK reveals no invasive tumor.
        • F2022-00175
          • FsA: Section shows fibroadipose tissue without malignancy. The immunohistochemical stain of CK reveals no invasive tumor.
          • FsB: Section shows a piece of pancreatic tissue and a lymph node. The pancreatic tissue reveals infiltration of chronic inflammatory cell and fibrosis. No invasive tumor is found. The immunohistochemical stain of CK reveals no invasive tumor. Metastatic adenocarcinoma is seen in the lymph node. The immunohistochemical stain of CK is positive.
    • 2022-04-18 Frozen section
      • Preliminary diagnosis:
        • FsA: Soft tissue, SMA root, biopsy — negative for malignancy
        • FsB: Pancreas, biopsy — in favor of reactive change
          • Lymph node, site?, excision — metastatic adenocarcinoma (1/1)
    • 2022-04-08 Percutaneous gall bladder drainage
      • Distention of the gallbladder (by CT images).
      • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the gallbladder smoothly.
    • 2022-04-06 2D transthoracic echocardiography, TTE
      • Findings
        • Heart size: Dilated LA; AsAo (33mm); (LA volume: 60 ml, LA volume index: 47 ml/m2)
        • Thickening: LVPW
        • Mitral E/A = 80 / 117 cm/s (E/A ratio = 0.68); Dec.time = 222 ms; Heart rate = 87 bpm
        • Septal MA e’/a’ = 5.4 / 9.3 cm/s; Septal E/e’ = 14.7 ;
        • Lateral MA e’/a’ = 8.3 / 16.9 cm/s; Lateral E/e’ = 9.6 ;
        • IVC size 12 mm with inspiratory collapse >50%
      • Conclusion:
        • Indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA.
        • Normal LV and RV systolic function.
        • Aortic valve sclerosis with trivial AR; trivial MR; trivial TR; mild PR.
        • Mildly dilated proximal ascending aorta (33mm).
    • 2022-03-31 Patho - pancreas biopsy
      • Tumor, pancreas, EUS FNA biopsy — Adenocarcinoma
      • Microscopically, the sections show a picture of blood, fibrin material, glandular or nest tumor cells with enlarged, hyperchromatic nuclei and nucleoli embedded in some fibrous stroma and focal mucin secretion, compatible with adenocarcinoma, moderately differentiated.
    • 2022-03-31 Fine needle aspiration biopsy - pancreas
      • Smears show clusters of papillary atypical hyperchromatic cells.
      • Malignancy is favored. Please correlate with the clinical presentation.
    • 2022-03-31 Endoscopic Ultrasonography, EUS
      • Using EUS-UCT 260 showed
        • 1.) dilatation of CBD up to 9.6mm filled with hyperechoic material
        • 2.) distented GB full of hyperechoic material.
        • 3.) a 22*20mm hypoechoic lesion at pancreatic head region
      • Diagnosis
        • Pancreatic head tumor with CBD obstruction, s/p EUS-FNA + ROSE
      • Suggestion
        • pursue pathological result
    • 2022-03-30 MRI - pancreas
      • Findings:
          1. There is an ill-defined homogeneous mass measuring 2 x 1.4 cm in the pancreatic head, causing bile duct, galbladder and pancreatic duct dilatation, and it showing hypointensity on T1WI and iso-intensity on both T2WI and DWI. During dynamic study, this tumor shows relative poor enhancement at arterial phase, portal-venous phase and delayed phase images.
          • Adenocarcinoma of the pancreatic head is highly suspected.
          • Please correlate with EUS.
        • There are symmetrical soft tissue lesions encompass the celiac trunk and superior mesenteric artery that may be metastases?
        • There are few enlarged nodes in hepatoduodenal ligament and aortocaval space.
        • Abdominal aorta shows atherosclerosis, ectasia 2.8 cm and mild intramural thrombus formation.
      • IMP:
        • Adenocarcinoma of the pancreatic head is highly suspected.
    • 2022-03-28 CT - abdomen
      • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage): T1cN1M0, stage IIB
    • 2022-03-25 CXR
      • Tortous aorta with calcification is noted.
    • 2022-03-25 SONO - abdomen
      • Diagnosis
        • Gallbladder stone and sludge
        • CBD dilatation
        • MPD dilatation
      • Suggestion
        • Please correlate with other image study
    • 2022-01-24 CT - abdomen
      • Fat stranding along celiac trunk, common hepatic artery, splenic artery and proximal SMA.
      • A vascular blush at right hepatic lobe.
    • 2021-12-24 Patho - colon biopsy
      • Colon, transverse, biopsy — tubular adenoma with low grade dysplasia
    • 2021-11-29 CTA - pelvis
      • History and indication: endometrial CA s/p ATH at VGH without F/U
      • S/P hysterectomy. No evidence of tumor recurrence.
    • 2021-11-29 SONO - abdomen
      • Diagnosis
        • Fatty liver, mild
        • Hepatic calcified lesion, S5
        • Slightly dilatation of MPD, body
      • Suggestion
        • Please correlate with other image study and clinical condition
  • consultation
    • 2022-06-14 Infectious Disease
      • A
        • This is a case of pancreatic adenocarcinoma and neutropenic fever.
        • 2022/06/08 B/C: yeast-like.
        • Agree with your use of mycamine as antifungal treatment. Keep one anti-fungal agent is suggested.
        • Please f/u the final B/C results and adjust it according to the susceptibility.
        • Please check recheck B/C 3~5 days later.
    • 2022-04-28 Hemato-Oncology
      • Q
        • This 66-year-old woman has past history of
          • 1). Endometrial cancer s/p op and chemotherapy more than 20 years ago,
          • 2). hypertension,
          • 3). abdominal pain suspect with partial intestinal obstrucion related in 2014/11/14.
        • This time, she suffered from water diarrhea right after oral intake for 2+ months and fever with chills for 2 days. She was admitted to GI ward with the initial diagnosis of infectious gastroenteritis.
        • Abdominal MRI with MRCP was performed on 3/30 and revealed adenocarcinoma of the pancreatic head being highly suspected. EUS/FNAB on 3/31 and pathology revealed Adenocarcinoma. GS was consulted and the surgeon had well explain to families. PPN was added since 4/01. Follwed up abdomen echo revealed gall bladder distension, dilatation of CBD and bilateral IHD. PTGBD was done for bilitary tract obstruction drainage on 4/08. She was transferred to GS ward on 2022/04/14.
        • After transferred to GS ward, with stable condition after pancreatitis subsided, she was scheduled to receive Whipple’s operation. During operation, a >2cm pancreatic head tumor with SMA & SMV invasion and multiple enlarged LNs over SMA root were noted. Pancreatic tumor biopsy was done and the enlarged LN was harvested. The frozen section showed positive of malignancy of LN. After informing the family, GJ byass, cholecystojejunostomy were done instead.
        • The patient was currently with stable condition and would start full liquid diet today.
        • We needed your expertise for further management. Thank you!
      • A
        • Impression:
          • Pancreatic adenocarcinoma, T4N1M0, stageIII s/p 20220418 GJ byass, cholecystojejunostomy, excision of intraabdominal tumor
          • During operation, a >2cm pancreatic head tumor with SMA & SMV invasion and multiple enlarged LNs over SMA root were noted.
        • Suggestion:
          • For unresectable disease at surgery and local advanced disease, systemic therapy is indicated. We will discuss with patients later.
            • if good performance: FOLFIRINOX, or Gemcitabine + albumin-bound paclitaxel
            • if poor performance status, may consider gemcitabine alone or capecitabine.
        • If patient agrees, we take over this case.
    • 2022-04-01 General and Gastrointestinal Surgery
      • A
        • suggest:
          • please D/D ductal adenocarcinoma or NET
          • nutrition support with PPN or TPN for 1-2 weeks
          • check PFT and 2D echo
          • we will f/u this case
    • 2022-03-25 Psychosomatic medicine
      • Q
        • Anxiety was noted. So we need you evaluation and suggestion of this patient. Thank you very much
      • A
        • I. Psychiatric impression:
          • Anxiety state
          • Watery diarrhea, cause to be determined
          • suspected somatic symptom disorder
          1. Clinical course and presentation:
          • This 66 years old female had medical history of
            • 1). Endometrial cancer s/p op and chemotherapy more than 20 years ago,
            • 2). hypertension,
            • 3). abdominal pain suspect with partial intestinal obstrucion related in 2014/11/14.
          • This time, she suffered from persistent watery diarrhea since 4 months ago, and had detailed GI examination done at our hospital but in vain.
          • The patient claimed to have fair appetite, diarrhea after eating, fair sleep but notable distress feeling to her somatic symptoms.
          • Death thinking would occur but denied proper suicidal plans. Her body weight had decreased around 13 kg in recent 4 months.
          • According to the observation of the medical team, the patient often refrained from oral intake probably due to diarrhea.
          • She admitted to have fear of cancer relapse or some unknown medical disease despite reassurance by doctors.
          • She also claimed to be easily anxious, she was ever admitted to NTUH psy department for unknown psychiatric diagnosis, and lost follow-up.
          • She had been taking alprazolam from our GI department and told to have good response.
          1. Suggestion:
          • Sulpiride 1# HS
          • Alprazolam 1# PRNBID
          • Treat underlying reason for diarrhea, re-assurance of exam results
  • surgical operation
    • 2022-04-18
      • Surgery
        • GJ byass
        • cholecystojejunostomy
        • excision of intraabdominal tumor, malignancy
      • Finding
        • pancreatic head tumor, >2cm
        • multiple enlarged LNs over group 15
        • SMA and SMV invasion
  • chemoimmunotherapy
    • 2022-05-10 ~ undergoing - gemcitabine + cisplatin

[assessment]

  • Hypomagnesimia (2022-06-30 1.3 mg/dL) could be caused by gastrointestinal loss (chemotherapy induced diarrhea, panceas disease) or renal loss (cisplatin, loop diuretic furosemide). Magnesium sulfate 10% 20mL IVD QD has been prescribed.
  • The level of serum albumin was around 2.5 g/dL for most of June. BW 41 kg, BH 150 cm (2022-06-30); BMI 18.2 kg/m2, mild thinness. It is recommended to eat more to prevent malnutrition.
  • It should be noted that blood sugar readings fluctuate at high levels even after insulin was administered.
  • Both TPR and BP were stable during this hospital stay.

701358791

220630

  • present illness
    • In the case of this 41-year-old female, she was diagnosed with endometrial adenocarcinoma IA Grade 2 and High grade endometrial stromal sarcoma (ESS), stage IIB post-hysterectomy at MacKay Memorial Hospital in 2021-08, where she was offered C/T & R/T for post-operative treatment, however, she hesitated and sought a second opinion at NTUH. The patient had a CT in 2021-10 at NTUH for tumor staging. However, she did not return to the clinic for the results.
  • exam finding
    • 2022-06-28 CXR
      • S/P Port-A infusion catheter insertion.
      • Ground glass opacity in right lung.
    • 2022-06-13 Renal ultrasound (Nephrology)
        1. Normal right kidney except for a suspected AML, middle pole
        1. Left hydronephrosis
        1. Tumor compression of the left kidney
        1. PCN in the left renal pelvis
        1. Mass lesion in the pelvic region
    • 2022-06-04 CT - abdomen, pelvis
      • Recurrent endometrial cancer with LNs and lung metastases.
      • S/P bil. PCN.
      • Splenomegaly.
    • 2022-06-04 KUB + L-spine Lat
      • S/P bil. pig-tail catheters indwelling.
    • 2022-06-04 Electrocardiogram, ECG
      • Sinus tachycardia
    • 2022-05-24 KUB
      • S/P bil. pig-tail catheters indwelling.
    • 2022-05-06 PCN - pigtail revision
      • Obstruction of left PCN catheter.
      • Revision of the catheter smoothly.
    • 2022-05-06 KUB
      • The psoas shadow is clear.
      • Increased density in the abdominal cavity is found.
      • Stool impaction at the abdominal cavity is noted.
      • Scoliotic alignment of the lumbar spine is found.
      • Calcified dot(s) is found at left paravertebral region, ureter stone(s) is most likely.
    • 2022-04-28 KUB
        1. s/p pigtail insertion in the bilateral uper abdomen.
        1. increased density in the lower abdomen. Nature?
    • 2022-04-28 Electrocardiogram, ECG
      • Sinus tachycardia with Premature atrial complexes
      • Nonspecific ST abnormality
      • Abnormal ECG
    • 2022-04-12 Patho - lymphnode biopsy
      • Soft tissue, pelvis, left, CT guided biopsy — sarcoma, high grade.
      • IHC stains: vimentin (+), CD10 (-), CK (-), CK7 (-), CK20 (-).
      • Section shows cores of soft tissue with infiltration of epithelioid and spindle shaped neoplastic cells.
    • 2022-04-08 CT - abdomen, pelvis
      • Local recurrent endometrial sarcoma with lymph nodes and lung metastases is highly suspected.
    • 2022-04-08 Tc-99m MDP whole body bone scan
      • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral elbows, S-I joints, hips and knees. Benign joint lesions are more likely.
    • 2022-04-06 CT - abdomen
      • Ovarian cancer with lymph nodes metastases and lung metastais is highly suspected. Please correlate with CA125 and contrast-enhanced CT.
      • Splenomegaly is noted, nature? Please correlate with clinical condition.
    • 2022-04-06 Gynecologic ultrasonography
      • ATH
      • Bilateral kidney hydronephsis
      • Suspected pelvis mass > 30 cm
  • consultation
    • 2022-06-28 Urology
      • Q
        • ER Examination: 3.
          • Medical device problems > acute peripheral severe pain (8-10)
          • The patient reported pain in the right waist and obstruction of the right renal drainage tube for 3 days
      • A
        • Ultrasound showed right hydronephrosis, combined with new left foot swelling and bilateral waist and back skin swelling, water moved to extravascular dehydration
        • The problem may not be solved by simply changing the tube, and there may be other factors to consider
        • A swelling on the left foot may indicate aggravation of the condition despite the patient’s pain and shortness of breath, and the patient hopes for active treatment
        • I will perform change Pigtail with c-arm+ contrast medium
        • Do blood test CXR for suspect infection and renal failure
    • 2022-05-27 Urology
      • Q
        • Bilateral hydronephrosis S/P Percutaneous Nephrostomy (PCN)
          • right Percutaneous Nephrostomy revision on 20220523.
          • left Percutaneous Nephrostomy revision on 20220506.
      • A
        • drainage function seems fine
        • no ecchymosis or leakage now
        • urine from right PCN is clear
        • there is no need of change Pigatail now
        • change of pigtail now may still be ainful
        • plan add morphine or other pain killer
    • 2022-04-19 Dermatology
      • Q
        • Newly erupted itchy skin rash at bilateral popliteal regions, elbows, axillary cavity, inguinal regions, metacarpophalangeal joints were noted for one day. So, we need your expertise on evaluation or some sugggestion. Thank you very much!
      • A
        • This patient suffered from multiple erytheamtous papules-plaques on bil legs after 2 dose BNT vaccine for months.
        • Imp: Vasculitis
        • Suggestion:
            1. Please check CBC/DC, ANA,TSH, C3/C4, ASLO, Anti-HBsAg, Anti-HCV
            1. Zaditen 1 / Bid
            1. Xyzal * 1 Hs
            1. SInpharderm * 1 tube/bid
            1. Topsym cream * 6 tubes/bid
        • Thanks!
    • 2022-04-13 Cardiology
      • Q
        • This 41y/o female was diagnosed with Endometrial endometrioid adenocarcinoma IA Grade 2 and High grade endometrial stromal sarcoma(ESS), stage IIB s/p hysterectomy in 2021/08 in MacKay Memorial Hospital.
        • This time was admitted to our Onco’s ward under impression of suspect local recurrent endometrial stromal sarcoma with lymphnode and lung metastasis and obstructive uropathy with UTI.
        • After admission, high blood pressure levels were found but the patient denied history of HTN. For suspect newly diagnosed HTN, we need your expertise for evaluation or some suggestion or OPD f/u. Thank you very much!
      • A
        • I was consulted for elevated hospitalized BP.
        • A
          • avg. 160-200 mmHg
          • EKG: LVH, sinus
          • Taking steroid, hydralazine now
        • Suggestion:
            1. Add amlodipine 1pc QD; keep hydralazine
            1. Pain/anxiety relief
            1. Treat underlying diseases
    • 2022-04-08 Urology
      • A
        • S
          • This time, the the patient had progressive low back pain, poor appetite with body weight loss (20Kg) in these 2-3 months.
        • O
          • Abdomen CT: pelvic mass with lymph nodes metastases and lung metastais; external compression/invasion to left ureter and bilateral hydronephrosis.
        • A
          • Bilateral ureteral catheterization +/- left pigtail insertion is indicated.
          • We’ve visited the patient and discussed with the patient about the further treatment plan.
          • Current treatment plan is not well established, pathology report of the pelvic mass is need.
        • P
          • Please contact us when pathology is done. Thank you.
          • Urine retention is noted from 2 CT scans. Foley insertion is recommended.
    • 2022-04-08 Rheumatology and Immunology
      • Q
        • For vasculitis-like skin rashes noted at the four limbs and APS not be excluded , we need your expertise on evaluation or some suggesion. Thank you very much!
      • A
        • Diffuse skin purpura over four limb for several months, no active joint pain, after vaccination?
        • O
          • Cr 0.89
          • ALT 6
          • CRP 8.97
          • urnie protein-, ob+
        • Suggestion
          • suspected r/o vasculitis, may check ANA, anti-SSA, SSB, SM/RNP, DSDNA, ANCA, anti-cardiolipin IG/IGM, B2glycoprotein 1, lupus anticoagulation, C3/C4
          • may keep prednisolone 1#bid.
    • 2022-04-06 Obstetrics and Gynecology
      • A
        • S
          • G0, SEX(-), TOCC(-)
          • PH: s/p hystectomy
          • Personal history:
            • Endometrial endometrioid adenocarcinoma IA Grade 2 => s/p hysterectomy (2021/08 op at MacKay H)
            • High grade endometrial stromal sarcoma, ESS, IIB, s/p hysterectomy (2021/08 op at MacKay H, without CT/RT)
            • Vasculitis under medication of fexofenadine, prenisolone, and MgO
          • Family history: denied
        • O
          • CT:
            • Ovarian cancer with lymph nodes metastases and lung metastais is highly suspected.
            • Please correlate with CA125 and contrast-enhanced CT.
          • Lab data: Cre = 0.89, eGFR = 74
          • PE: no pitting edema, no swelling over bilateral legs.
          • Echo:
            • Pelvic mass > 30 cm, suspected ESS with bilateral hydronephrosis
        • Impression and plan:
            1. OPD follow up for suspect endometrial stromal sarcoma with lymph node and lung mets.
            1. Please check CA125, CA199, CEA
            1. Pain control
            1. please consult urology for bilateral hydronephrosis being noted.
  • surigcal operation
    • 2022-04-13 Percutaneous Nephrostomy
    • 2022-04-12 Percutaneous Nephrostomy
  • chemoimmunotherapy
    • 2022-04-20 ~ undergoing - paclitaxel + carboplatin

==========

2022-06-30

  • There is severe pain a number of times after PCN, which could be caused by the renal drainage tube. Unbalanced drainage amount recorded, 2022-06-29 right PCN 900 and left PCN was 0. It may be worthwhile to investigate the underlying causal factors.
  • Several months of sinus tachycardia have been observed, which could have been caused by hydralazine. In addition to acting as an antihypertensive, ivabradine may also lower heart rate, which might be worth considering.

2022-05-20

  • The patient was diagnosed with high grade endometrial stromal sarcoma in August 2021 and has been treated with paclitaxel + carboplatin since April 2022.
  • Lab data reported on 2022-05-19 showed grossly normal. No issue with active prescription.

701072376

220629

{cholangiocarcinoma, recurrenct, liver and lung mets, s/p colon cancer}

[objective]

  • lab data
    • HGB
      • 2022-06-28 7.9 g/dL
      • 2022-06-09 8.0 g/dL
      • 2022-05-29 8.9 g/dL
      • 2022-05-13 8.3 g/dL
      • 2022-04-26 9.4 g/dL
      • 2022-04-25 8.9 g/dL
      • 2022-04-22 8.2 g/dL
      • 2022-04-07 9.3 g/dL
      • 2022-03-29 10.9 g/dL
      • 2022-03-22 11.1 g/dL
      • 2022-03-11 11.0 g/dL
      • 2022-02-23 12.6 g/dL
      • 2022-02-18 12.5 g/dL
      • 2021-12-17 13.8 g/dL
      • 2021-11-01 12.5 g/dL
      • 2021-03-20 14.1 g/dL
      • 2021-03-19 15.5 g/dL
    • Creatinine
      • 2022-06-28 1.91 mg/dL
      • 2022-06-21 1.79 mg/dL
      • 2022-06-09 1.43 mg/dL
      • 2022-05-29 1.79 mg/dL
      • 2022-05-13 1.68 mg/dL
      • 2022-04-25 1.24 mg/dL
      • 2022-04-22 2.17 mg/dL
      • 2022-04-07 1.62 mg/dL
      • 2022-03-29 1.44 mg/dL
      • 2022-03-22 1.29 mg/dL
      • 2022-03-11 1.36 mg/dL
      • 2022-02-23 1.23 mg/dL
      • 2022-02-18 1.13 mg/dL
      • 2022-01-20 1.04 mg/dL
      • 2021-12-17 1.41 mg/dL
      • 2021-11-03 1.11 mg/dL
      • 2021-11-01 1.40 mg/dL
      • 2021-09-16 1.17 mg/dL
      • 2021-08-16 1.40 mg/dL
      • 2021-03-19 2.11 mg/dL
      • 2021-03-02 1.30 mg/dL
      • 2020-12-08 1.27 mg/dL
      • 2020-09-15 1.40 mg/dL
      • 2020-03-25 1.30 mg/dL
      • 2020-02-21 1.30 mg/dL
  • exam findings
    • 2022-06-09, 2022-05-29 Electrocardiogram, ECG
      • Sinus bradycardia with sinus arrhythmia
    • 2021-12-21 CT
      • S/P right lobectomy and cholecystectomy. S/P colostomy.
      • Multiple recurrent tumors in the liver and peritoneal seeding, lymph nodes metastasis, bilateral lung metastasis. (recurrent cholangiocarcinoma or colon malignancy?)
    • 2021-11-16 CT
      • recurrent cholangiocarcinoma in left hepatic lobe with lung and Rt cardiophenic angle LNs metastases. small airways disease in lungs too.
    • 2021-09-01 Myocrdial perfusion SPECT with persantin
      • Mildly improved myocardial perfusion to LV compared with the previous study on 2020-06-02, indicating resposne to current therapy.
      • There is still mild myocardial ischemia at the basal inferolateral wall and apical inferolateral wall (LCx territory) of LV. 3. No dilatation of LV is noted.
    • 2021-06-02 Myocrdial perfusion SPECT with persantin
      • Probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the inferoapical wall and inferolateral wall and mild myocardial ischemia at the inferoseptal wall and posterior wall.
    • 2021-03-25 MRI - L-spine
      • mild spondylolisthesis at L5-S1
      • herniated discs in the L2/3, L3/4, and L4/5 discs.
    • 2019-05-21 CT
      • Recurrent cholangiocarcinoma or artifact 1.8 cm in S4 of the liver is suspected. Please correlate with AFP, CEA, and MRI.
    • 2018-08-07 SONO - Hepatobiliary
      • Post right hepatectomy. Poor defined gallbladder.
    • 2018-03-23 Surgical pathology Level V
      • Diagnosis: Liver, intrahepatic bile ducts, S5, right lobectomy - Cholangiocarcinoma
        • Pathologic Staging (AJCC): pT2N0(cMx); Stage II if cM0
      • Microscopic examination
        • Histologic Type: Cholangiocarcinoma
        • Histologic Grade: GIII (Poorly differentiated)
        • Tumor Growth Pattern: Mass-forming
        • Microscopic Tumor Extension: Tumor confined to hepatic parenchyma
        • Small Vessel Invasion (L): Present
        • Additional Pathologic Findings: Cirrhosis
        • Hepatitis: Chronic hepatitis B
        • Ishak Modified HAI Grading: Score = 4 (interphase hepatitis = 1/4, confluent necrosis = 0/6, focal necrosis = 1/4, portal inflammation = 2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
        • Fatty Change: Present (5%)
        • IHC for tumor cells: CK7(+), Hepa-1(-), Arginase(-)
    • 2018-02-23 Surgical pathology Level V
      • Diagnosis: Liver, c;inical histroy of colorectal adenocarcinoma, neele biopsy - Adenocarcinoma.
      • IHC:
        • CK7(+), CK20(-), CDX-2(-): dis-favor colorectal origin;
        • Hepatocyte(-), Arginase(-): dis-favor hepatocellular carcinoma.
        • CK19(+): favor cholangiocarcinoma.
    • 2018-01-19 CT
      • Irregular low density(around 2.4cm) in right lobe liver, suspected liver metastasis.
      • Post-op with colostomy in left abdomen.
    • 2017-07-12 Tc-99m MDP whole body bone scan
      • A new lesion in a middle C-spine in comparison with the previous study on 2013-07-17, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up.
      • Significantly increased radioactivity in the mandilbe, dental problems may show this picture.
      • Suspected benign lesions in the maxilla, bilateral sternoclavicular junctions, L-S junction, bilateral shoulders, bilateral knees, and bones/joints of right foot.
    • 2017-07-12 CT
      • Suspect small airway disease in lower lobes of lung.
      • Gallstones.
    • 2007-10-26 Patho
      • rectal adenocarcinoma pT2N1M0 s/p abdominal perineal resection.
  • consultation
    • 2021-11-02 Thoracic Medicine
      • Q
        • This 70-year-old male patient had past history of:
            1. Smoking for about 40-50 years, has quit for 2 years.
            1. Rectal adenocarcinoma, pT2N1M0 s/p abdominal perineal resection on 2007/10/26.
            1. Hypertension for more then 10 years and diabetes for 5 years with medical control.
            1. Ileus for times since 2012/08/06.
            1. Right hip osteoarthritis s/p total hip replacement on 2013/12/25.
            1. Right knee osteoarthritis s/p TKR on 2018/01/25 at Chang Hua Hospital of MOHW
            1. Right cholangiocarcinoma, pT2N0M0; Stage II s/p right lobectomy + lymph node dissection + cholecystectomy on 2018/03/22.
        • He was under regular medical treatment in our CV, Neurology, Meta OPD in the recent years.
        • According to patients and his daughter, he complained of dyspnea after walking about 50 meters in the recent 1 years. The symptoms lasted for 5~10 minutes and subsided after rest. So, we arranged 2D transthoracic echocardiography on 2021/09/01, which showed EF 80%; 1. Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.; 2. Normal LV and RV systolic function.; 3. Mild aortic valve sclerosis. Tl-201 stress myocardial perfusion scan on 2020/06/02, which showed: probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the inferoapical wall and inferolateral wall and mild myocardial ischemia at the inferoseptal wall and posterior wall. We arrange CAG on 2021/11/02. Therefore, we need your expertise to evaluate his condition and make further comments. Thank you very much!
      • A
        • S
          • This 70 y.o male was a case of rectal adenocarcinoma, right cholangiocarcinoma and HTN. This time, he was admitted due to progressive dyspnea and suspected CAD. Now, we were consulted for further evaluation about possible lung disease.
          • Smoking: 1 ppd for 40-50 years and quit for 2 years
        • O
          • 2021-08-24 CXR: mild cardiomegaly, LLL retrocardiac opacity r/o consolidation or other etiology
          • 2021-10-19 PFT: FEF 25-75% <60%, suspected small airway disease with significant bronchodilator response
        • Suggestion:
            1. please follow up CXR, if LLL retrocardiac opacity still presented, Chest CT was indicaded
            1. please arrange Pulmonary provocation test for small airway disease (suspected underline asthma or airway hypersensitivity)
        • We will like to f/u this case if data complete
  • surgical operations
    • 2021-03-23
      • Surgery: tumors excision
      • Finding: multiple granulomatous polyps formation around the colostomy
  • chemotherapy regimen
    • 2022-04-07 - 5-FU + carboplatin + gemcitabine
    • 2022-02-23 ~ 2022-03-22 - 5-FU + cisplatin + gemcitabine

==========

2022-06-29

  • 2022-06-28 RBC 2.3 *10^6/uL, HGB 7.9 g/dL, MCV 105.7 fL => could be macrocytic anemia. Kentamin (B1, B6, B12) has been prescribed.
  • Gemcitabine could also induce macrocytosis. Gemcitabine related anemia incidence: 68%, grade 3 7%, grade 4 1%. This drug has been used since 2022-02-23. It could have accelerated the decline in HGB levels, however, there might also be other causal underlying conditions, as the decline has been documented since March 2021.
  • There is an obvious downward trend of HGB with a monthly drop of -0.5 g/dL.
    • 2022-06-28 7.9 g/dL
    • 2022-06-09 8.0 g/dL
    • 2022-05-29 8.9 g/dL
    • 2022-05-13 8.3 g/dL
    • 2022-04-26 9.4 g/dL
    • 2022-04-25 8.9 g/dL
    • 2022-04-22 8.2 g/dL
    • 2022-04-07 9.3 g/dL
    • 2022-03-29 10.9 g/dL
    • 2022-03-22 11.1 g/dL
    • 2022-03-11 11.0 g/dL
    • 2022-02-23 12.6 g/dL
    • 2022-02-18 12.5 g/dL
    • 2021-12-17 13.8 g/dL
    • 2021-11-01 12.5 g/dL
    • 2021-03-20 14.1 g/dL
    • 2021-03-19 15.5 g/dL
  • It is also possible for capecitabine-based regimens to cause anemia (72% to 80%, grades 3 or 4 <=3%)

2022-04-08

  • The serum creatinine level rises from 1.04mg/dL (2022-01-04) to 1.62mg/dL (2022-04-07), which should be addressed.
  • In the new regimen used during this hospital stay, cisplatin was substituted for carboplatin, which might mitigate renal toxicity.

2022-03-23

  • Since late February 2022, the patient has been receiving 5-FU + cisplatin + gemcitabine. No issue with current medication.
  • If a patient is not a candidate for a clinical trial or one is not available, and if S-1 is not available, gemcitabine plus cisplatin is recommended as a first-line regimen for patients with a good performance status. Another reasonable, possibly better tolerated option is gemcitabine plus oxaliplatin (GEMOX). Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) might also be considered.

701136097

220629

{right ovarian cancer, pT1c3N0 if cM0, FIGO IC3 s/p Op on 20200720}

  • lab data
    • Mg (Magnesium)
      • 2022-06-28 1.5 mg/dL
      • 2022-06-01 1.7 mg/dL
      • 2022-04-26 1.5 mg/dL
      • 2022-03-29 1.8 mg/dL
      • 2022-03-07 1.9 mg/dL
  • exam finding
    • 2022-04-08 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • S/p port-A placement with its tip at RA
      • The lung fields are clear.
      • Clear bilateral costophrenic angle is noticed.
      • Patent airway is found.
    • 2022-04-08 Electrocardiogram
      • Normal sinus rhythm
      • ST & T wave abnormality, consider inferior ischemia
      • Abnormal ECG
    • 2022-03-09 Body Fluid Cytology - ascites
      • pathologic diagnosis
        • Before IP C/T: Atypia
      • macroscopic examination
        • 11 cc pink clear ascites
      • microscopic examination
        • The smears show some lymphocytes, reactive mesothelial cells and few atypical cells in necrotic debris show hyperchromatic nuclei and degenerative quality. Follow up
    • 2022-02-17 Electrocardiogram
      • Normal sinus rhythm
      • T wave abnormality, consider inferior ischemia
      • Abnormal ECG
    • 2022-01-04 Patho - ovary (tumor)
      • diagnosis
        • Peritoneal nodule, right, debulking surgery — High-grade serous carcinoma, seeding
        • Subdiaphramatic, right, debulking surgery — High-grade serous carcinoma, seeding
        • Omentum, debulking surgery — High-grade serous carcinoma, seeding
        • Transverse colon, debulking surgery — High-grade serous carcinoma, seeding
      • microscopic examination
        • The sections show serous carcinoma composed of irregular branching of neoplastic papillae lined by high-grade tumor cells with tumor necrosis and fibrous stroma. The tumor shows nclar hyperchromasia, pleomorphism, prominent nucleoli and mitotic activity.
        • Immunohistochemical stain reveals CK7(+), WT-1(+), CK20(-) and PAX-8(+).
    • 2021-12-31 Colonoscopy
      • Diagnosis
        • Poor colon preparation
        • Internal hemorrhoid
      • Suggestion
        • Repeat colonoscopy under good colon preparation if needed
      • Complication
        • No immediate complication
    • 2021-12-10 CT - lung/mediastinum/pleura
      • Imp: No evidence of pulmonary mets.
      • Liver metastasis. Statinoary.
      • Splenic hilar mets. Stable.
    • 2021-11-23 Mammography
      • Impression:
        • Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative. - annual screening.
    • 2021-11-18 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Peritoneal seeding and liver metastases.
    • 2021-11-16 CXR
      • No active lung lesion.
      • Borderline cardiomegaly.
      • Thoracic spondylosis.
    • 2021-08-25 SONO - Abd for follow-up
      • A homogeneous hyperechoic nodule 0.9 cm in S6 of the liver is noted that may be hemangioma? Follow up is indicated.
      • A renal cyst measuring 0.76 cm in right upper pole is noted.
    • 2021-08-10 CT - abdomen, pelvis
      • Imp: s/p ATH and BSO. No evidence of recurrent/residual tumor in the current study.
    • 2021-02-23 CT - abdomen, pelvis
      • S/P hysterectomy and oophorectomy. Suggest follow up.
      • Renal cysts.
      • Right adrenal nodule, suspected adrenal adenoma.
    • 2020-07-20 Patho - uterus (with or without SO) neoplastic
      • Ovarian Fallopian tube Peritoneum Cancer Checklist (Based on AJCC 8th ed. and FIGO 2014)
      • pathologic diagnosis
        • Ovary, right, debulking surgery —- high-grade serous carcinoma
        • Ovary, left, debulking surgery —- high-grade serous carcinoma
        • Fallopian tube, right, debulking surgery —- high-grade serous carcinoma
        • Fallopian tube, left, debulking surgery —- high-grade serous carcinoma
        • Uterus, corpus, ebulking surgery —- intramural leiomyomas
        • Uterus, cervix, debulking surgery —- negative for malignancy
        • Omentume, debulking surgery —- negative for malignancy
        • Lymph node, left iliac, dissection — negative for malignancy (0/7)
        • Lymph node, left obturator, dissection — negative for malignancy (0/6)
        • Lymph node, right iliac, dissection — negative for malignancy (0/7)
        • Lymph node, right obturator, dissection — negative for malignancy (0/12)
        • Lymph node, left paraaortic, dissection — negative for malignancy (0/8)
        • Lymph node, left paraaortic, dissection — negative for malignancy (0/8)
      • pTNM stage: pT1c3N0(If cM0); FIGO IC3
      • microscopic examination 1. Histologic type: serous carcinoma
        • Histologic grade: high grade
        • Contralateral ovary involvement: present
        • Tumor side ovarian surface involvement: present
        • Contralateral ovary surface involvement: present
        • Right tube involvement: present
        • Left tube involvement: present
        • In situ adenocarcinoma in right and/or left fallopian tube: absent
        • Right adnexa soft tissue involvement: absent
        • Left adnexa soft tissue involvement: absent
        • Pelvic soft tissue involvement: absent
        • Uterine serosa involvement: absent
        • Omentum involvement: absent
        • Uterine Cervix involvement: absent
        • Endometrium involvement: absent
        • Myometrium involvement: absent
        • Appendix involvement: not received
        • Largest Extrapelvic Peritoneal Focus (required only if applicable): N/A
        • Peritoneal/Ascitic Fluid - Malignant (positive for malignancy) (N20202-02181)
        • Regional Lymph Nodes: Negative for metastasis: (0/ 48)
        • Other organs or specimens involvement: absent
    • 2020-07-20 Body Fluid Cytology - ascites
      • pathologic diagnosis
        • Positive for malignancy
      • macroscopic examination
        • 33 cc red turbid ascites
      • microscopic examination
        • The smears show lymphocytes, mesothelial cells & many hyperchromatic atypical cell clusters, compatible with malignant tumor. Clinical correlation and confirmatory biopsy is advised.
    • 2020-07-20 Frozen section
      • Ovary, right, frozen section— malignant tumor
      • IHC stain — WT-1(+), CK7(+), CK20(-), vimentin(-)
    • 2020-07-17 CT - abdomen, pelvis
      • Findings
        • There is a well-defined lobulated soft tissue mass measuring 9.8 x 7.3 x 10 cm in right pelvis with suggestive mild fat and calcification component and it shows directly attached the uterus. Teratocarcinoma of right ovary is highly suspected. The differential diagnosis include serous carcinoma. Please correlate with clinical condition and MRI.
        • There is another soft tissue lesion 3.3 x 2.4 cm in left adnexa that may be left ovarian cyst or cystic tumor.
        • There are three Uterine myoma 3.5 cm, 3.2 cm, and 1 cm.
        • Ascites in abdomen and pelvis is noted. In addition, soft tissue lesions in the omentum is suspected that may be tumor seeding? Please correlate with ascites cytology.
        • A renal cyst measuring 1.3 cm in left upper pole is noted.
    • 2019-05-07 Surgical pathology Level IV
      • Uterus, cervix, biopsy — Mild dysplasia (CIN I)
      • Uterus, endocervix, ECC — Mild dysplasia (CIN I)
    • 2019-08-06 2Gynecologic ultrasonography
      • Uterine myoma
  • surgical operation
    • 2022-01-03
      • Surgery
        • Right diaphragmatic tumor resection and repair
      • Finding
        • Table consultation.
        • Two tumors about 3.0cm x 2.0cm x1.0cm in size respectively over right diaphragm.
      • Procedure
        • Part of right diaphragm was resected by electrocautery. Lung injuury was prevented during dissection. The 2 tumors were removed together.
        • The diaphragmatic defect was closed by interrupted No.2 Silk. No more defected was detected by palpation.
    • 2020-07-20
      • Surgery
        • Cystoscopy and bilateral ureter catheter insertion
      • Finding
        • normal bladder mucosa
        • huge posterior indentation
        • no bladder tumor was seen
    • 2020-07-20
      • Surgery
        • Diagnosis
          • Right ovarian tumor suspected malignancy s/p debulking surgery.
        • Operation
          • Debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy + BPLND)     - Finding
        • Right ovarian tumor, suspected malignancy.
        • Frozen: malignancy
    • 2019-06-26
      • Dysplasia of cervix (uteri)
      • Finding
        • Uterus: Anteversion, 9 cm.
        • Scanty endocervical and some endometrial tissue were curetted out.
        • Estimated blood loss: 15 mL, Blood transfusion: nil, complication: nil.
      • Procedure: Fractional dilatation and curettage
        • Put the patient on lithotomy position.
        • Douching, skin disinfection and skin draping as usual.
        • Sounding: Anteversion, 9 cm.
        • Cervical dilatation to Hegar No. 7.
        • Curette endocervical canal and uterine cavity.
        • Pack the vagina with a piece of gauze
  • chemoimmunotherapy
    • 2022-02-10 ~ undergoing - docetaxel + carboplatin + gentamicin (+ bevacizumab since 2022-03-08)
    • 2021-12-31 - liposome doxorubicin + carboplatin
    • 2020-09-12 ~ 2021-01-27 - paclitaxel + carboplatin

[note]

  • Causes of magnesium depletion (2022-06-29 https://www.uptodate.com/contents/hypomagnesemia-causes-of-hypomagnesemia )
    • Gastrointestinal losses
      • Diarrhea, malabsorption and steatorrhea, and small bowel bypass surgery
      • Acute pancreatitis
      • Medications
        • PPIs
      • Genetic disorders
        • Intestinal hypomagnesemia with secondary hypocalcemia
    • Renal losses
      • Medications
        • Diuretics (loop and thiazide)
        • Antibiotics (aminoglycoside, amphotericin, pentamidine)
        • Calcineurin inhibitors
        • Cisplatin
        • Antibodies targeting epidermal growth factor (EGF) receptor (cetuximab, panitumumab, matuzumab)
      • Volume expansion
      • Uncontrolled diabetes mellitus
      • Alcoholism
      • Hypercalcemia
      • Acquired tubular dysfunction
        • Recovery from acute tubular necrosis
        • Postobstructive diuresis
        • Post-kidney transplantation
      • Genetic disorders
        • Bartter/Gitelman syndrome
        • Familial hypomagnesemia with hypercalciuria and nephrocalcinosis
        • Autosomal dominant isolated hypomagnesemia (Na-K-ATPase gamma subunit, Kv1.1 and cyclin M2 mutations)
        • Autosomal recessive isolated hypomagnesemia (EGF mutation)
        • Renal malformations and early-onset diabetes mellitus (HNF1-beta mutation)

==========

2022-06-29

  • The serum magnesium level has declined over the past four months. The last dose of cisplatin was dated on 2022-04-27. In PharmaCloud, there are no records for loop diuretics, thiazide diuretics, or PPIs. Diarrhea, malabsorption or steatorrhea?
  • Magnesium level time series
    • 2022-06-28 1.5 mg/dL
    • 2022-06-01 1.7 mg/dL
    • 2022-04-26 1.5 mg/dL
    • 2022-03-29 1.8 mg/dL
    • 2022-03-07 1.9 mg/dL
  • The laboratory results on 2022-06-28 were considered acceptable for the continuation of the palliative chemotherapy.

2022-06-02

  • This is a 59 y/o female with high-grade serous carcinoma accompanied by peritoneal seeding and liver mets underwent debulking surgery on 2020-07-20 and right diaphragmatic tumor resection on 2022-01-03.
  • Her treatment regimens have included paclitaxel and carboplatin (2020-09 ~ 2021-01), liposome doxorubicin and carboplatin (2021-12) as well as the current regimen of docetaxel, carboplatin, and bevacizumab since the first quarter of 2022.
  • The laboratory results on 2022-06-01 were considered acceptable for the continuation of the palliative chemotherapy. Lenograstim 250 mcg SC will be administered following chemotherapy on 2022-06-03.

701342752

220629

{intra-hepatic cholangiocarcinoma with lung and right adrenal mets}

  • exam finding
    • 2022-06-29 ECG
      • Normal sinus rhythm
      • Possible Inferior infarct, age undetermined
      • Abnormal ECG
    • 2022-04-08 Cathay General Hospital Discharge Summary
      • intra-hepatic cholangiocarcinoma with lung and right adrenal mets, cT4N1M1, post Nivolumab, Gemcitabine and TS-1 cycle 6 with progression in lung mets, post PHDFL cycle 1
      • hepatitis B virus carrier. HTN. CKD.
    • 2022-04-01 CT - abdomen (Cathay General Hospital)
      • Related main clinical history: Large liver tumor s/p biopsy with adenocarcinoma diagnosed favored intrahepatic cholangiocarcinoma.
    • 2022-03-11 CT - chest (Cathay General Hospital)
      • multiple lung metastasis. s/p treatment follow up.
      • progression in number and size of bilateral lung nodules and bilateral lower pleural tickening.
      • findings:
        • Stationary upto nearly 14cm right hepatic poor contrast enhancing tumor invading right suprarenal region.
        • Multiple varying size upto nearly 3.5cm bilateral hepatic tumors.
        • Obliteration of right adrenal gland by right hepatic tumor invasion.
        • Peritoneum & mesentery: Mild increased ascites.
        • Lymph nodes: Stationary hepatic hilar, periceliac and aortocaval LAP.
      • impression:
        • Previous similar study on 2021/12/31.
        • Stationary upto n nearly 14cm right hepatic hypovascular tumor invading right suprarenal and adrenal gland.
        • Multiple varying size upto nearly 3.5cm bilateral hepatic tumors.
        • Mild increased ascites.
        • Stationary hepatic hilar, periceliac and aortocaval LAP.
    • 2021-12-31 Follow-up abdominal + pelvis CT and chest CT
      • liver tumor intra-abdominal and left supraclavicular fossa LN metastasis and bilateral lung metastasis.
      • mild ascites.
    • 2021-12-27 Patho - liver biopsy (Cathay general hospital)
      • Cholangiocarcinoma

[assessment]

  • Tumour of the biliary tract with metastatic disease to the lungs and adrenals. Earlier this year, carboplatin and HDFL were administered and severe adverse effects were reported. There had been six cycles of Nivolumab, Gemcitabine, and TS-1 prior to that.
  • Unresectable and metastatic biliary tract cancer is commonly treated with these regimens:
    • 5-fluorouracil + oxaliplatin
    • 5-fluorouracil + cisplatin
    • Capecitabine + cisplatin
    • Capecitabine + oxaliplatin
    • Gemcitabine + albumin-bound paclitaxel
    • Gemcitabine + capecitabine
    • Gemcitabine + oxaliplatin
    • Gemcitabine + cisplatin + albumin-bound paclitaxel
  • In the discharge summary from Cathay general hospital, no info is found regarding what kind of severe adverse effects caused by carboplatin/HDFL. Gemcitabine as a single agent might be worth considering.
  • It is possible to extend the options in the event that a particular gene pattern is approved:
    • NTRK gene fusion positive: entrectinib, larotrectinib
    • MSI-H/dMMR/TMB-H: pembrolizumab
    • FGFR2 fusion or rearrangements: pemigatinib, infigratinib
    • IDH1 mutation: ivosidenib
    • BRAF-V600E mutation: dabrafenib + trametinib

700520713

220628

  • exam finding
    • 2022-06-27 CXR
      • General osteoporosis
      • Multilevel compression fracture of T-L spine
    • 2022-06-27 ECG
      • Sinus tachycardia
      • Left axis deviation
      • Inferior infarct, age undetermined
      • ST & T wave abnormality, consider lateral ischemia
      • Prolonged QT
    • 2022-06-14 CT - abdomen, pelvis
      • S/P gastrectomy.
      • No evidence of tumor recurrence.
    • 2022-05-24 SONO - abdomen
      • Normal sonographic study of the hepatobiliary system.
    • 2022-05-24 CXR
      • Patchy opacity projecting in the right upper medial lung or mediastinum shows stationary. Follow up is indicated.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2022-04-12 CT - brain
      • Imp: Brain atrophy.
    • 2022-01-25 CT - abdomen, pelvis
      • S/P subtotal gastrectomy.
    • 2021-11-23 Bone densitometry - spine
      • Osteoporosis
    • 2021-11-09 T- L-spine AP + Lat.
      • Compression fracture of T7, T10, T12 and L4.
      • Atherosclerosis of the aorta.
    • 2021-07-20 Patho - stomach subtotal/total (tumor)
      • pathologic diagnosis
        • Stomach, anastomosis area, radical total gastrectomy —- Adenocarcinoma, poorly differentiated, s/p subtotal gastrectomy about 30 years ago
        • Small intestine, duodenum, radical total gastrectomy —- Adenocarcinoma, by direct invasion —- Neuroendocrine tumor,
        • G1 Soft tissue, anterior abdominal wall, excision —- Adenocarcinoma, by direct invasion
        • Omentum,radical total gastrectomy —- Negative for malignancy
        • Lymph node, lesser curvature, group 1, 3, 5, 7, 8, 9, 11p, 12a, dissection —- Adenocarcinoma, metastatic (2/14)
        • Lymph node, greater curvature, group 2, 4, 6, 14v, dissection —- Adenocarcinoma, metastatic (4/16)
        • AJCC 8 th edition pTNM Pathology stage:
          • Adenocarcinoma: pStage IIIB, pT4bN2 (if cM0)
          • Neuroendocrine tumor: pStage I, pT1N0 (if cM0)
      • microscopic examination
        • Histologic Type: Adenocarcinoma, Lauren classification of adenocarcinoma: Intestinal type
        • Histologic Grade : G3: Poorly differentiated, undifferentiated
        • Tumor Extension: Tumor invades adjacent structures/organs (specify) abdominal wall soft tissue
        • Lymphovascular Invasion: present
        • Perineural Invasion: present
        • Regional Lymph Nodes: lesser curvature: 2/14; greater curvature: 4/16
        • The immunohistochemical stains reveal CD56(+) and Synaptophysin(+). The Ki-67 is < 3%.
        • Intestinal metaplasia: present
        • Low-grade dysplasia: present
        • High-grade dysplasia: absent
        • Helicobacter pylori-type gastritis: absent
        • Autoimmune atrophic chronic gastritis: absent
        • Polyp(s): absent
    • 2021-06-30 CT - liver, spleen, biliary duct, pancreas
      • Findings:
        • S/P subtotal gastrectomy with suggestive BI anastomosis?please correlate with clinical history.
        • There is a lobulated wall thickening lesion in the stomach, beyond anastomosis area, that is compatible with adenocarcinoma. The fat plane between the gastric lesion, pancreatic body and abdominal wall shows obliteration that may be directly attached or invasion?
        • There are six enlarged nodes in the gastrohepatic ligament and adjacent omentum area that may be metastatic nodes.
      • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
    • 2021-05-13 Patho - stomach biopsy
      • Stomach, Remnant gastric cancer, s/p biopsy — Adenocarcinoma.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
    • 2021-05-13 SONO - abdomen
      • Hepatic tumor prob. hemangioma
      • Susp. parenchymal liver disease
  • consultation
    • 2021-07-13 Gastroenterology

[assessment]

  • Lab data (2022-06-27) low K (2.3 mmol/L), high NT-proBNP (2561 pg/mL), high hs-Troponin I (561.5 pg/mL), high WBC (13.64 *10^3/uL) -> underlying cardiac conditions? following EKG indicated inferior infarct and lateral ischemia.
  • pH 7.475, pCO2 22.8 mmHg, HCO3 16.4 mmol/L (2022-06-27) -> Hyperventilation to mitigate hypoperfusion of the heart?
  • no issue with active prescription.

701378989

220627

  • lab data
    • 2022-06-27 PD-L1 22C3 S22-9396
      • Tumor type: Lung cancer
      • 2022-06-27 Tumor Proportion Score (TPS): 60%
    • 2022-06-22 PD-L1 28-8 S22-9396
      • Tumor type: Lung cancer
      • Tumor Cell (TC) staining assessment: TC < 1%
      • Percentage of 28-8 expressing tumor cells (%TC): 0%
    • 2022-05-27
      • Protein, total 5.8 g/dL
      • Albumin 52.9 %
      • Alpha-1 5.2 %
      • Alpha-2 13.4 %
      • Beta 16.1 %
      • Gamma 12.4 %
      • M-peak Negative
      • A/G Ratio 1.10
      • IgG/A/M Kappa/Lambda No Paraprotein
    • 2022-05-26
      • B2-Microglobulin 3379 ng/mL
    • 2022-05-25
      • SCC 1.6 ng/mL
      • HBsAg Nonreactive
      • HBsAg (Value) 0.52 S/CO
      • Anti-HBc Reactive
      • Anti-HBc-Value 3.74 S/CO
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.16 S/CO
      • Anti-HBc IgM Nonreactive
      • Anti-HBc IgM Value 0.12 S/CO
  • exam finding
    • 2022-06-24 CXR
      • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
      • Patchy opacity of the right lower lung zone was noted, which might be bronchogenic carcinoma. Please correlate with CT.
      • Enlargement of cardiac silhouette.
      • S/P pigtail catheter implantation at right CP angle.
      • Spondylosis of the T-spine
    • 2022-06-15 Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • S2022-9396
        • Tumor type: adenocarcinoma
        • Tumor location: lung
        • Testing assay: SP142 Assay (Ventana)
        • Testing platform: BenchMark XT
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
        • Control slide result: Pass,
        • Adequate tumor cells present (>= 50 viable tumor cells): Yes,
      • Result:
          1. Tumor cell (TC) staining assessment: TC category: TC < 1%
          1. Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      • Note:
          1. TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
          1. IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-06-15 Tc-99m MDP whole body bone scan
      • Highly suspected cancer with multiple bone metastases in the skull, both rib cages, sternum, some C-, T- and L-spine, sacrum, bilateral pelvic bones, and bilateral femoral trochanters.
      • Increased activity in the maxilla and bilateral shoulders, probably post-traumatic change or bone mets.
    • 2022-06-14 MRI - brain
      • Known a case of lung cancer. Numerous enhancing nodular lesions over both cerebral hemispheres and cerebellum and brainstem, compatible with metastases.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • 2022-06-09 Patho - lung transbronchial biopsy
      • Lung, RML/RLL, bronchoscopic biopsy — adenocarcinoma, moderately differentiated
      • Sections show bronchial mucosa with invasive solid and acinar tumor cells in submucosa and lymphatic vessels.
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(-), WT-1(-) and PAX8(-). The results are in favor of primary lung adenocarcinoma.
    • 2022-06-09 Body Fluid Cytology - bronchial washing
      • Smears show benign bronchial and squamous cells and clusters of atypical hyperchromatic and pleomorphic cells. Malignancy is favored. Please correlate with the clinical presentation.
    • 2022-05-27 CT - abdomen, pelvis
      • Findings:
        • There is a well-defined mild heterogeneous mass in RLL of the lung, measuring 9 cm in size (the largest dimension) that may be bronchogenic carcinoma with total obstruction of RLL bronchus and RLL collapse.
          • In addition, there are multiple small nodules in both lung that are c/w lung to lung metastases.
          • There are several enlarged nodes in the paratracheal space that may be metastastic nodes.
          • There is massive right side pleura effusion with lobulated thickening in the visceral pleura that may be pleura tumor seeding. Please correlate with pleura effusion cytology.
        • There is a poor enhancing lesion 5 mm in S8 of the liver that may be flow artifact or tumor?
        • There is minial wall thickening of right UPJ causing hydronephrosis and delayed contrast excretion of right kidney.
          • Please correlate with retrograde pyelography to R/O chronic UPJO or urothelial cell carcinoma.
        • There is a cystic lesion in right adnexa measuring 3.2 cm in size but no evidence of wall thickening or mural nodule.
          • Simple right ovarian cyst is highly suspected.
          • Please correlate with GYN. sonography.
          • In addition, There is a exophytic soft tissue mass measuring 4.4 cm in size protruding from right side uterus with central calcification that may be myoma.
        • There are diffuse bony metastases in the T-spine, L-spine and pelvis.
        • There are soft tissue lesions in the omentum that are c/w tumor seeding.
      • Impression:
        • Primary lung cancer in RLL with lung to lung metastases, right pleura metastases, diffuse bony metastases, and carcinomatosis is suspected.
        • Chronic UPJO or urothelial cell carcinoma at right UPJ causing obstructive uropathy is suspected. Please correlate with retrograde pyelography.
    • 2022-05-27 Gynecologic ultrasonography
      • IUD in situ
      • Multiple myomas
    • 2022-05-12 MRI - L-spine
      • Findings
        • Diffuse numerous lesions with T1-hypointensity and mild T2-hyperintensity involving both anterior and posterior elements of every vertebral body from C4 to S5 and iliac bones vivisble in these images, indicating bony metastases.
        • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild to moderate spinal canal stenosis and bilateral mild to moderate neuroforaminal narrowing at L1-2-3-4-5-S1, esp L4-5.
        • Mild scoliosis of L-spine.
        • Dilatation of right renal calyces andproximal ureter, indicating obstructive uropathy.
        • A well-deifned cystic mass, about 37 mm, with T1-hypointensity and T2-hyperintensity in right aspect of pelvic cavity. R/O right ovarin cystic tumor.
        • Massive pleural effusion in right lung field with right lung collapse.
      • IMP:
        • Diffuse bony metastases involving vertebral column and bony pelvis as described.
        • Right hydronephrosis and hydroureter.
        • Suspected right ovarian cystic tumor (37 mm).
        • Right massive pleural effusion.
        • Suggest further evaluation.
    • 2022-05-12 Bone densitometry - spine
      • L-spines BMD (AP view) performed by DXA revealed:
        • AP L-spines, BMD of L1-4 0.711 gms/cm2, about 3.1 SD below the peak bone mass ( 68 %) and 0.1 SD above the mean of age-matched people ( 103 %).
      • IMP: osteoporosis
  • consultation
    • 2022-06-20 Dermatology
      • A
        • This patient suffered from erytheamtous patches on vaginala area for days
        • Imp:
            1. Intetrigo
            1. Dyshidrotic dermatitis
        • Suggestion:
            1. Sinpharderm * 1 tube + topsym cream * 2 tubes/bid(feet)
            1. Zalain cream * 1 tubes/bid
    • 2022-06-16 Radiation Oncology
      • A
        • This 78-year-old woman case of Lung adenocarcinoma with brain and bone metastases, stage IV. Lower back pain developed. Whole body bonew scan on 2022/06/15 showed T-L spine bone metastasis.
        • Palliative RT is indicated. CT-simulation will be arranged on 2022-06-20. Plan to deliver 30 Gy/ 10 fx to the spine T11-L3. RT will start around 2022-06-21 or -06-22. Thank you very much.
    • 2022-06-08 Dermatology
      • A
        • This patient suffered from erytheamtous patches on vaginal area for months
        • Imp: Subacute dermatitis
        • Suggestion:
            1. Zalain cream * 2 tubes/bid
            1. Zaditen 1 */Bid
    • 2022-05-27 Urology
      • A
        • Right hydronephrosis + creatinine: normal
        • PCN was suggested if further C/T is indicated.
        • After discussed with the patient and families, they refused PCN.
        • Consult us again if they changed their mind.
    • 2022-05-27 Obstetrics and Gynecology
      • A
        • 78y/o, female, G3P3. Admitted due to diffuse bony metastases involving vertebral column and bony pelvis. Pleural effusion s/p tapping, cytology: Malignancy (+)
        • S:
          • Back pain for 1 year
          • The pain was diffuse to whole body and can not take care of herself in recent month
        • O:
          • Elevated tumor marker, CEA:941, CA153:405, CA125:364.8, CA199:358
          • Abdominal cT on 2022/05/27 showed right pleural effusion, rigth hydroneprosis, uterine myoma and R/O overain tumor.
          • Sono: uterus: AVf: 5.3x3.5cm, IUD in situ, EM:0.57
          • Uterine myoma about 4.6x3.7cm and 2.2x1.7cm
          • CDS: no fluid
        • IMP:
          • IUD in situ
          • Uterine myoma
        • P:
          • Tumor biopsy may be arranged after discussion with the family

{valganciclovir not for herpes}

  • There is a diagnosis of an unspecified herpesvirus infection.
  • Valganciclovir is a nucleoside analog group of antiviral medication that is used to treat cytomegalovirus (CMV) infections. It is not effective against herpes simplex virus (HSV) infection. ( https://www.sciencedirect.com/science/article/pii/B9780128012383994066 )
  • Most patients with a first episode of genital HSV can be treated with oral therapy. IV acyclovir is typically reserved for the management of complicated infection (eg, central nervous system and disseminated disease). ( https://www.uptodate.com/contents/treatment-of-genital-herpes-simplex-virus-infection )
  • The 2021 United States Centers for Disease Control and Prevention (CDC) guidelines recommend any of the following oral treatment options (doses based on normal renal function). Therapy should be administered for 7 to 10 days. However, on occasion, a patient may continue to have new lesions even after completing a 10-day course. When this happens, the course is typically extended by five to seven days.
    • Acyclovir: 400 mg three times daily
    • Famciclovir: 250 mg three times daily
    • Valacyclovir: 1000 mg twice daily
  • All three agents appear to have similar efficacy for the treatment of a first episode of genital herpes, and the margins of safety and tolerability are excellent. Valacyclovir is generally administered since it is dosed less frequently than the others, although oral acyclovir may be preferred in certain settings as it can be less expensive.

700953139

220624

{pseudomyxoma peritonei}

  • Lab data
    • CA-199
      • 2022-06-17 141.06 U/mL
      • 2022-06-02 171.303 U/mL
      • 2022-05-10 137.16 U/mL
      • 2022-04-22 128.052 U/mL
      • 2022-04-21 137.226 U/mL
      • 2022-03-25 195.97 U/mL
      • 2022-03-09 223.51 U/mL
      • 2022-02-18 225.74 U/mL
      • 2022-02-04 217.96 U/mL
      • 2021-12-07 223.03 U/mL
      • 2021-11-19 251.47 U/mL
      • 2021-11-09 180.081 U/mL
      • 2021-10-22 216.17 U/mL
      • 2021-10-05 185.36 U/mL
      • 2021-09-14 161.169 U/mL
      • 2021-07-23 138.66 U/mL
      • 2021-07-13 136.710 U/mL
      • 2021-04-20 197.23 U/mL
      • 2021-04-07 221.4 U/mL
      • 2021-03-26 182.849 U/mL
      • 2021-03-23 188.093 U/mL
      • 2021-03-08 187.400 U/mL
      • 2021-02-19 231.475 U/mL
      • 2021-02-04 222.5 U/mL
      • 2021-02-04 229.390 U/mL
      • 2021-01-15 195.585 U/mL
      • 2021-01-04 117.21 U/mL
      • 2020-12-31 183.1 U/mL
      • 2020-12-23 196.630 U/mL
      • 2020-12-23 204.470 U/mL
      • 2020-12-04 219.81 U/mL
      • 2020-11-25 232.83 U/mL
      • 2020-11-09 284.23 U/mL
      • 2020-10-02 273.88 U/mL
      • 2020-08-04 215.15 U/mL
    • CA-125
      • 2022-06-17 120.114 U/mL
      • 2022-06-02 61.224 U/mL
      • 2022-05-10 47.427 U/mL
      • 2022-04-19 38.267 U/mL
      • 2021-10-22 45.773 U/mL
      • 2021-10-05 49.708 U/mL
      • 2021-09-14 40.944 U/mL
      • 2021-07-23 38.211 U/mL
      • 2021-07-13 35.203 U/mL
      • 2021-04-20 31.553 U/mL
      • 2021-04-07 31.265 U/mL
      • 2021-03-23 29.899 U/mL
      • 2021-02-04 35.661 U/mL
      • 2020-10-06 113.319 U/mL
      • 2020-08-04 421.600 U/mL
  • exam finding
    • 2022-06-16 Abdomen - standing (diaphragm)
      • Spondylosis with scoliosis of the L-spine with convex to right side.
      • Ascites is noted.
      • Wedge deformity at left lateral aspect of L2 and L3 vertebral body and right lateral aspect of L4 vertebral body are noted. Please correlate with clinical symptom and history.
      • Pseudomyxoma peritonei with multiple curvelinear calcification in the peritoneum.
    • 2022-04-15 CT - abdomen, pelvis
      • FINDINGS:
        • Prior CT (2022/01/11) identified carcinomatosis (pseudomyxoma peritonei) in peritoneal cavity and lesser sac with indentation defects at the liver capsule are noted again, stable in size that is compatible with stable disease.
        • Few small renal cysts on both kidney are noted.
        • Spondylosis with scoliosis of the L-spine with convex to right side. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon from L2 to L5.
        • Bilateral mild Pleura effusion are noted.
      • IMP:
        • Carcinomatosis (pseudomyxoma peritonei) show stable disease.
    • 2022-03-08 Standing KUB
      • Curvelinear calcification in the whole abdomen is noted that is c/w pseudomyxoma peritonei.
      • Ascites is noted.
      • Compression fracture of L3, L4 and L5 vertebral body causing Spondylosis with scoliosis of the L-spine with convex to left side.
    • 2022-03-08 CXR
      • S/P port-A implantation.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Hypoinflation of both lung is noted.
      • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease.
      • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
      • Spondylosis with scoliosis of the T-spine with convex to right side
    • 2022-01-11 CT - abdomen, pelvis
      • findings
        • There are diffuse soft tissue tumores in the peritoneum with calcifications, suggesting peritoneal carcinomatosis. Stationary.
        • Left renal cyst, 1.8cm.
      • impression
        • Diffuse peritoneal carcinomatosis, stationary.
        • Left renal cyst.
        • Lumbar spine scoliosis.
    • 2021-10-09 CT - abdomen, pelvis
      • findings
        • Cystic lesions (n>30) with calcified wall inside abdominal cavity is found. In comparison with CT dated on 2021-07-06, the size and extension of the lesions are stationary.
        • Clear bilateral basal lungs is found.
        • Scoliotic alignment of the thoracolumbar spine is noted.
        • Degenerative change of the bony structure with marginal osteophyte formation is identified.
        • No evidence of liver tumor but the liver surface is compressed by calcified cystic lesions.
        • Tortous aorta with calcification is noted.
      • Imp:
        • Colon cancer with Cancerous carcinomatosis. Stationary.
    • 2021-07-06 CT - abdomen, pelvis
      • findings
        • There are diffuse soft tissue tumores in the peritoneum with calcifications, suggesting peritoneal carcinomatosis. Stationary.
        • Left renal cyst, 1.8cm.
        • Lumbar spine scoliosis.
      • Impression:
        • Diffuse peritoneal carcinomatosis, stationary.
        • Left renal cyst.
        • Lumbar spine scoliosis.
    • 2021-04-21 Patho - colon biopsy
      • Cecum, biopsy — Tubulovillous adenoma with low grade dysplasia and focal high grade dysplasia.
      • Section(s) show(s) fragment(s) of villous polypoid colonic mucosal tissue with proliferative finger-like mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia. There is focal high grade dysplasia.
    • 2021-04-20 Colonoscopy
      • Findings
        • 90cm to cecum, ulcerative lesion at cecum, biopsy
        • multiple external compression over S colon, and D colon
      • Diagnosis
        • ulcerative lesion primary tumro or secondary invasion are both consider
      • Suggestion
        • follow pathology
      • Complication
        • No immediate complication
    • 2021-04-16 CXR
      • S/P pacemaker.
      • No active lung lesion.
      • Borderline cardiomegaly.
      • Thoracolumbar spondylosis and scoliosis.
    • 2021-04-16 ECG
      • Sinus rhythm with Premature atrial complexes
      • Prolonged QT
      • Abnormal ECG
    • 2021-03-22 CT - abdomen, pelvis
      • Progression of peritoneal carcinomatosis.
    • 2021-01-17 CXR
      • S/P port-A implantation.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Hypoinflation of both lung is noted.
      • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease.
      • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
      • Spondylosis with scoliosis of the T-spine with convex to right side
    • 2020-12-11 CT - abdomen
      • Carcinomatosis (pseudomyxoma peritonei) show progressive disease.
    • 2020-08-21 Patho - soft tissue tumor, extensive resection
      • diagnosis
        • A. Labeled as “peritoneal carcinomatosis”, biopsy with frozen section (F2020-332FS) — mucnous adenocarcinoma. IHC stains: CK20 (+), pax-8 (-), GI origin is considered.
        • B. Labeled as “peritoneal carcinomatosis: omentum and small intstinal tumor”, biopsy (S2020-11921A) — mucinous adenocarcinoma
        • C. Labeled as “peritoneal carcinomatosis: right pelvic wall tumor”, biopsy (S2020-11921B) — mucinous adenocarcinoma.
      • microscopic description
        • Sections of F20-332FSA1-2, S20-11921A1-4 and B show mucnous adenocarcinoma.
        • IHC stains: CK20 (+), pax-8 (-), GI origin is considered.
        • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+).
    • 2020-08-07 Colonoscopy
      • Findings
        • The scope reach the transverse colon near hepatic flexure under fair colon preparation; a large ulcerative tumor occupying almost whole colon lumen thus the scope could not be passed through: highly suspect colon cancer: biopsy was taken for six pieces.
        • diverticulosis: sigmoid colon
      • Diagnosis
        • transverse colon tumor(near hepatic flexure), suspect colon cancer, post biopsy (incomplete exam: insertion to transverse colon only because of tumor obstruction)
        • diverticulosis: sigmoid colon
      • Complication
        • No immediate complication
  • surgical operation
    • 2020-08-19
      • Surgery
        • Bilateral DBJ insertion
      • Finding
        • Bilateral DBJ insertion, 6Fr 24cm DBJ, was performed smoothly
      • Procedure
        • Under ETGA
        • Lithotripsy position
        • Drapping and disinfection as usual
        • 6Fr 24cm DBJ was inserted smoothly
        • Patient stood the procedure well
    • 2020-08-19
      • Surgery
        • Diagnosis: Peritoneal carcinomatosis
        • Operation: exploratory laparotomy and tumor excision
      • Finding
        • Supraumbilical midline vertical skin incision
        • Uterus: atrophy, tense contact with bladder,
        • Adnexa:
          • LAD: not seen due to severe adhesion and tumor seeding
          • RAD: not seen due to severe adhesion and tumor seeding
        • CDS: invisible due to tumor mass occupied
        • Ascites: bloody , about 500 ml
        • Omentum: multiple hard, variablesized nodules
        • Liver: grossly normal & smooth
        • Appendix: not seen due to severe adhesion and tumor mass occupied
        • Multiple mucin-contained mass about 3~5 cm over intestine, peritonium and pelvic wall
        • Residue tumor: multiple tumors, maximal diameter about 5 cm, over intestine, colon and peritoneal wall
        • Note
          • Estimated blood loss:minimal
          • Blood transfusion:nil
          • Complication:nil
      • Procedure
        • Put the patient on the lithotomy position
        • Vaginal douching, on Foley, skin disinfection with beta-iodine, and skin draping.
        • Make midline vertical skin incision and open the abdominal wall layer by layer.
        • Serous ascites 20 ml, send for cytology
        • Apply auto-retractor and pack up the intestine.
        • Dissect the tumor and send for frozen section: mucinous adenocarcinoma
        • Consult CRS for futher evaluation
        • Insert a 15 J-P drain at the cul-de-sac.
        • Close the abdomen layer by layer.
        • Skin approximation with 4-0 Dexon. 
    • 2020-08-05
      • Surgery
        • Dilatation and curettage
      • Finding
        • Uterus: Anteversion, 5 cm.
        • Scanty endocervical and some endometrial tissue were curetted out.
        • A pollyp about 1.5x0.5cm at 1 o’clock was protuding from cervix.
        • Estimated blood loss: minimal, Blood transfusion: nil, complication: nil.
      • Procedure
        • Put the patient on lithotomy position.
        • Douching, skin disinfection and skin draping as usual.
        • Sounding: Anteversion, 5 cm.
        • Cervical dilatation to Hegar No. 8.
        • Curette endocervical canal and uterine cavity.
        • Polypectomy was perfomred.
        • Check bleeding.
  • consultation
    • 2020-09-02 Family Medicine
      • Q
        • Colonscopy was performed on 2020/08/07 which revealed transverse colon tumor (near hepatic flexure), suspect colon cancer but biopsy showed tubular adenoma. CRS was consulted for exp.Lap with tissue proven and possible colostomy or ileostomy. Then she transfered to GYN ward on 2020/08/18 and underwent 1) Bilateral Double J insertion 2) exploratory laparotomy and tumor excision on 2020/08/19. Family refused colostomy or ileostomy. During the surgery, little tumor tissue was removed due to severe adhesion. Pathology on 2020/08/19 showed mucinous adenocarcinoma. IHC stains: CK20(+), pax-8 (-), GI origin is considered. Post operation then transfer to SICU for care on 2020/8/19-20. She still complained of abdominal fullness and vomiting. Owing to elevated D-dimer, Clexane was given. After evaluation by CRS Dr. Chen, repeated surgery for colostomy is not suggested due to poor prognosis. IPP and family meeting done on 2020/08/27 and she was transferred to oncology ward for further management. At ONC ward, consciousness clear and vital signs was stable. Abdominal fullness and pitting edema 4+ was noted. Keep liquid diet, smofkabiven and albumin infusion. Owing to terminal stage of mucinous adenocarcinoma of colon with peritoneal carcinomatosis metastasis, we need your expertise for hospice combined care, thanks.
      • A
        • Due to terminal stage of mucinous adenocarcinoma of colon with peritoneal carcinomatosis metastases, we were consulted for further evaluation.
        • When we visited, the patient lied on bed and her family stood by her. Her consciousness was clear and she asked that what time could she receive treatment. We will arrange hospice combined care first.
    • 2020-08-12 Colorectal Surgery
      • After admissoin, self paid of albumin with diuretics was given for right massive pleural effusion and ascites. Empirical antibiotics with Flumarin was given from 8/2 to 8/4, we shifted to Tapimycin from 8/4 due to still fever with chills and we repeat the blood culture. Owing to suspect ovarian or colon caner,series of examination were done. EGD showed Reflux esophagitis LA Classification grade A. PPI with Dexilant was given from 2020/8/4.
      • Reports:
        • Gynecologist was also consulted and D&C done on 2020/08/06 which endometrium curretage/biopsy showed endometrial polyp with few bland mucnous gland.
        • Bone scan on 2020/08/06 revealed No strong evidence of bone metastasis.
        • Colonscopy was performed on 2020/08/07 which revealed transverse colon tumor(near hepatic flexure), suspect colon cancer.Biospy on 2020/08/12 showed tubular adenoma.
        • Abdomen: soft, mild marked distended, palpable irregular masses(+), no peritoneal signs
        • Passage of little liquid stool
        • Tumor markers all elevated (CEA, CA19-9, CA12-5)
      • A: Peritoneal carcinomatosis with massive ascites and right pleural effusion, origin?
      • P:
        • Please consult RAD or CS for right pleural effusion drainage, and sent for cytology
        • Suggest echocardiography and pulmonary function test for pre-op evaluation
        • Exp.Lap with tissue proven and possible colostomy or ileostomy may be considered for further oncological treatment
        • We’ll follow this patient and arrange the operation next week
        • Please inform us if any problems
    • 2020-08-04 Obstetrics and Gynecology
      • Q
        • This 69 y/o woman is a case of HTN without medication control. She also denied any other systemic disease. According to this patient and her daughter, her poor appetite and B.W loss(>5 Kg) in recent 2 weeks. Associated symptoms with fever and BT up to 38.0 degree C, oligouria, SOB, abdomen fullness, vomit (epigastric juice) and minimal dark stool passage. She ever to GI OPD on 7/30 where MgO plus Gascon plus Morpide were given and abdomen echo/PES were perform. However, her SOB with abdomen fullness progress on 8/01. Then she was sent to our ER. TOCC(-)
        • At ER, her vital signs 100/18/37.2 and BP 150/75mmHg. Lab revealed no leukocytosis VBG no acidosis and U/A(-). Microcytic anemia (Hb:7.9 MCV/MCH:66.1/19.1), Alb 2.9 and CRP elevated 16.43 were noted. CxR revealed right pleural effusion and cardiomegaly. Abdomen CT was perfrom on 2020/08/01 which revealed suspected peritoneal carcinomatosis with massive ascites and pleural effusion. Suggest tissue study (ovary origin? appendix origin?). Chest tapping was perform and drainage 1000ml. Under the impression of ovarian cancer with massive ascites and pleural effusion. She was admitted for further management. After admission, we arranged the bone scan on 8/5 and pending for tumor marker data. We need your expertise for further treatment, thanks.
      • A
        • P3, menopaused
        • C.C: SOB with abdomen fullness for 2 weeks
        • O:
          • no vaginal bleeding, no lifting pain
          • Echo: Endometrial thickning with papillary mass like lesion, Bilateral adnexa mass. Cul-de-sac: with some ascites, abdominal mass, suspect omentum cake.
        • Imp:
          • endometrial thickning
          • pelvic mass with ascites, origin unknown
        • P:
          • arrange D&C on 2020/08/05
          • arrange colonsocpy
          • sent abdominal ascites and pleural effusion to cell block
  • chemoimmunotherapy
    • 2022-06-06 ~ undergoing - FOLFIRI
    • 2022-03-17 ~ 2022-04-28 - FOLFIRI + ramucirumab (3 times)
    • 2021-09-02 ~ 2022-02-25 - FOLFIRI + bevacizumab (8 times)
    • 2021-08-13 - FOLFIRI
    • 2021-06-02 ~ 2021-07-30 - FOLFIRI + bevacizumab (4 times)
    • 2021-05-10 - FOLFIRI
    • 2020-11-23 ~ 2021-04-26 - FOLFIRI + bevacizumab (11 times)
    • 2020-09-07 ~ 2020-11-10 - FOLFIRI (6 times)

[assessment]

  • Nowadays, cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) represents the only treatment with potential chances of cure and long-term disease control of patients affected by PMP.
  • Exploratory laparotomy and tumor excision was performed on 2020-08-19, however the tumor adhesions were too serious, obscuring the surgical field and could not be removed completely. When surgery is not indicated due to comorbidities or for unresectable disease, systemic chemotherapy is considered, with the main aim to avoid progression and control symptoms. In general, a relatively unresponsiveness and chemoresistance of PMP cells to systemic chemotherapy is reported, due to their low proliferation rate and the uncertain drug availability in the mucinous microenvironment of tumor nodules. Moreover, tumor response is difficult to evaluate with standard radiological criteria, as PMP masses are mostly composed of mucin and it is unlikely to obtain a significant shrinkage even in case of full activity on tumoral cells. The results of systemic chemotherapy showed a response rate ranging between 8-20%, median OS between 26-56 months, and 1-year OS rate of 84-91. ( https://pubmed.ncbi.nlm.nih.gov/34885075/ )
  • While CA-199 has remained relatively stationary in first half of 2022, CA-125 has trended upward in the last three months.
  • Lab data
    • CA-199
      • 2022-06-17 141.060 U/mL
      • 2022-06-02 171.303 U/mL
      • 2022-05-10 137.160 U/mL
      • 2022-04-22 128.052 U/mL
      • 2022-04-21 137.226 U/mL
      • 2022-03-25 195.970 U/mL
      • 2022-03-09 223.510 U/mL
      • 2022-02-18 225.740 U/mL
      • 2022-02-04 217.960 U/mL
    • CA-125
      • 2022-06-17 120.114 U/mL
      • 2022-06-02 61.224 U/mL
      • 2022-05-10 47.427 U/mL
      • 2022-04-19 38.267 U/mL
  • FOLFIRI has been used to treat the patient since September 2020 by IVD. In practice, chemotherapy can also be administered intraperitoneally in the PMP patients. Intraperitoneal administration of chemotherapy is designed to maximize the chemotherapeutic dose delivered to peritoneal tumor nodules while minimizing systemic toxicity. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754301/ )

700022404

220623

{CNS DLBCL}

[objective]

  • exam findings
    • 2022-06-22 MRI - brain
      • Findings
        • An intra-axial tumor, about 48 mm, with heterogeneous enhancement, diffuse restriction, central necrosis and perifocal white matter edema, involving right temporofrontal lobe, and causing mass effect (including effacement of right hemicerebral cortical sulci, compression and displacement of lateral ventricles and midline shift to left side).
        • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
        • S/P right frontotemporal craniotomy.
        • Diffuse mild luminal irregularity without obvious stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
      • IMP: Right frontotemporal tumor with mass effect. Suspected recurrent lymphoma.
    • 2022-06-22 CT - brain
      • Findings
        • decreased intraventricular and extraventricular CSF spaces in the right supratentoral region.
        • a nodular lesion, about 52mm, in the right temporal lobe and right basal ganglion with moderate perifocal edema
        • unremarkable change in the skull base
      • IMP: an intra-axial tumor in the right temporal lobe and right basal ganglion.
    • 2022-03-29 MRI - brain: Right temporo-occipital enhancing tumors, regressed. Comparison: 2021/12/22 Brain CT, 2021/12/09 Brain MRI
    • 2022-03-28 CT - abdomen, pelvis: Right pulmonary hilar lymphadenopathy, stationary.
    • 2021-12-22 CT - Brain: Right temporoparietal tumors (lymphoma?) with progression mass effect as compare with CT study on 20211205, suggest clinical correlation.
    • 2021-12-09 MRI - Brain: Recurrent brain lymphoma. Old insults in left caudate head and splenium, stationary and mild general brain atrophy.
    • 2021-12-05 CT - Brain: Ill-defined heteregeneous lesions in right temporoparietal lobes. Brain metastasis or contusion hemorrhage, suggest clinical correlation. Focal hyperdensity along left frontal horn, suspected focal hematoma.
    • 2021-09-09 MRI - Brain: old insults in left caudate head and splenium, stationary as comapred with MRI on 20210609.
    • 2021-06-09 MRI - Brain: focal increased enhancement in the periventricular region of the right parietal lobe.
    • 2020-07-09 CT, MRI: showed no definite evidence of extra-crainial metastasis. (TMUH)
    • 2020-06-20 MRI: CNS lesion, then biopsy revealed DLBCL. (TMUH)
    • 2020H1 Initial presentation with blurred vision, especially, right eye, and personality change. (TMUH)
  • lab data
    • Methotrexate (Toxic: 24hr > 10, 48hr > 1, 72h > 0.1, unit: umol/L)
      • 2022-04-30 <0.040
      • 2022-04-29 0.070
      • 2022-04-28 0.557
      • 2022-04-02 0.138
      • 2022-04-01 0.530
      • 2022-03-11 0.041
      • 2022-03-10 0.133
      • 2022-03-09 1.181
      • 2022-02-14 0.045
      • 2022-02-13 0.119
      • 2022-02-12 2.548
      • 2022-01-25 0.061
      • 2022-01-24 1.784
      • 2022-01-23 0.091
      • 2021-12-31 0.043
      • 2021-12-30 0.160
      • 2021-12-29 2.552
      • 2021-03-05 0.071
      • 2021-03-04 0.214
      • 2021-03-03 1.141
      • 2021-01-26 0.046
      • 2021-01-25 0.175
      • 2021-01-25 1.032
      • 2020-12-30 <0.040
      • 2020-12-29 0.058
      • 2020-12-28 1.379
      • 2020-12-28 0.218
      • 2020-12-02 <0.040
      • 2020-12-01 0.065
      • 2020-11-30 0.239
      • 2020-11-30 0.902
      • 2020-11-05 0.083
      • 2020-11-04 0.151
      • 2020-11-03 0.333
      • 2020-11-02 1.185
  • consultation
    • 2022-01-03 Rehabilitation
      • Assessment
        • Diffuse large B-cell lymphoma with CNS invasion, stage IV s/p chemotherapy with MTR and chemotherapy with HD MTX, brain local recurrent
        • brain MRI 20211209: recurrent brain lymphoma and old insults in left caudate head and splenium, stationary and mild general brain atrophy.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: ambulation independent. transfer independent.
    • 2021-12-25 Neurosurgery
      • Q
        • This 68-year-old man patient is a case of Diffuse large B-cell lymphoma with CNS invasion, stage IV s/p chemotherapy with MTR and chemotherapy with HD MTX, brain local recurrent. Dizziness with nausea in 2021/12. Brain CT on 2021/12/05 showed 1) Ill-defined heteregeneous lesions in right temporoparietal lobes. Brain metastasis or contusion hemorrhage, suggest clinical correlation. 2) Focal hyperdensity along left frontal horn, suspected focal hematoma. 3) Brain atrophy. Brain MRI on 2021/12/09 showed recurrent brain lymphoma and old insults in left caudate head and splenium, stationary and mild general brain atrophy. Chest CT on 2021/12/11 showed no evidence of lymphadenopathy in the study, calcified coronary arteries is found and tiny nodule at Right lower lobe, stable. This time, for con’s drowsy with dizziness since yesterday. Therefore, he was snet to our ER and Brain CT on 2021/12/22 showed 1) Right temporoparietal tumors (lymphoma?) with progression mass effect as compare with CT study on 2021-12-05, suggest clinical correlation. 2) Brain atrophy. Now, for evaluate brain tumor operation. Thank you.
      • A
        • The 68 y/o male a patient with diffuse large B-cell lymphoma with CNS invasion, stage IV s/p chemotherapy with MTR and chemotherapy with HD MTX, brain local recurrent. We are consulted for surgical opinion.
        • We had well-explained risk and outcome to patient’s family. Surgical intervention is recommended if family agree and accept the risk and ouctome. (If Brain MRI with enhancement is not able to be done, please arrange CT with enhancement for navigation if possible for pre-operation evaluation)
    • 2020-10-30 Neurosurgery
      • This 67-year-old man patient is a case of Diffuse large B-cell lymphoma with CNS invasion, stage IV. This time, for right shoulder pain radiation to finger for weeks.
      • brain MRI favor post treatment change in corpus callosum and left inferior caudate head. band encephalomalacia in RT lateral occipital lobe. Mild cortical brain atrophy. no enhancing brain mass or nodule.
      • x-ray s/p C3-4 ACDF with lower cervical spondylosis
      • Plan: pain control, NS OPD follow-up
    • 2020-10-27 Ophthalmology
      • Q
        • This 67-year-old man patient is a case of CNS DLBCL, stage IVA. Crystal lymphoma invasion with bilateral blurred vision. Now, for bilateral eye evaluate and examnation. Thank you.
      • A
        • BV od for several months concurrent with CNS DLBCL
        • subjective VA stable compare to previous condition
        • patient refuse further work up for media opacity and cause of retina infiltrate od
        • BCVA: 0.2/0.6
        • IOP 16/16
        • Fd photo od: nasal and superior satellite retina infiltrate media mild blurred
  • treatment
    • 2021-12 ~ ongoing - methotrexate + temozolomide
    • 2020-07 ~ 2021-03 - methotrexate + temozolomide + rituximab
  • underlying diseases
    • DM and HTN are under medication management.

==========

2022-06-23

  • The patient had vomiting, poor appetite, drowsiness, and incontinence during last two days. 2022-06-22 Updated images revealed an intra-axial tumor in the right temporal lobe and right basal ganglion that could be a recurrent lymphoma with decreased intraventricular and extraventricular CSF spaces in the right supratentoral region.
  • Underlying health conditions are treated with corresponding drugs without issues.

2022-05-18

  • MRI (2022-03-29) and CT (2022-03-28) images showed stable right hilar lymphadenopathy, and regressed tumors in the right temporo-occipital region, as compared to the images taken in Dec 2021. The current regimen appears to have some beneficial effects.
  • According to lab records, methotrexate levels never reached toxicity levels. Lab data reported on 2022-05-09 indicated that liver and kidney function, CBC, WBC DC, electrolytes and b2 microglobulin were generally normal. The last item reinforced the aforementioned results of images.
  • Urine glucose 2+ reported on 2022-05-17 (blood sugar data points since this hospitalization: 232, 203, 176). In patients with normal kidney function, significant glycosuria does not generally occur until the plasma glucose concentration exceeds 180 mg/dL (10 mmol/L). DM is an important factor affecting the prognosis of patients with DLBCL. Moreover, hyperglycemia during treatment is related to the poor prognosis of patients with DLBCL. (reference: https://pubmed.ncbi.nlm.nih.gov/33858047/ ) SGLT2 inhibitor might serve as an optional alternative agent of lowering blood sugar.

2022-03-28

  • Recurrent DLBCL with brain mets, in progression (2021-12-22 CT).
  • The patient got good response with methotrexate + temozolomide + rituximab during July 2020 to March 2021, and he is now on methotrexate + temozolomide since December 2021.
  • No IHC or Karyotype or FISH results found in HIS5.
  • The frequency of CNS involvement in systemic NHL varies depending at least partially upon the aggressiveness of the NHL subtype. Approximately 2 to 10 percent of patients with aggressive subtypes of systemic NHL (eg, DLBCL) will experience direct involvement of the CNS at some time during their course. The incidence is much higher in highly aggressive NHL (eg, Burkitt lymphoma/leukemia, lymphoblastic lymphoma) and lower in indolent NHL (eg, follicular lymphoma). Peripheral nervous system (PNS) involvement by lymphoma is rare.
  • It is unknown whether the risk of CNS relapse has changed as initial treatment of these diseases has evolved. Several retrospective studies have suggested that the incidence may be lower among patients with B cell NHL treated with rituximab-containing therapy or etoposide-containing therapy. Other studies have found no difference in the incidence of CNS relapse in the pre- versus post-rituximab era.
  • Diffuse large B-cell lymphoma with secondary involvement of the central nervous system treated with R-IDARAM (rituximab 375 mg/m2 IV day 1; methotrexate 12.5 mg by intrathecal injection day 1; idarubicin 10 mg/m2/day IV days 1 and 2; dexamethasone 100 mg/day IV infusion over 12 h days 1-3; cytosine arabinoside 1000 mg/m2/day IV over 1 h days 1 and 2; and methotrexate 2000 mg/m2 IV over 2 h day 3.) and median follow-up for surviving patients was 49 months. At 2 years, estimated progression-free survival (PFS) was 39% and overall survival (OS) was 52%. Encouraging outcomes were reported in patients with new disease, with 5-year estimated PFS of 50% and OS 75%.

2022-02-11

2022-01-24

  • blood sugar lab readings are above normal range under current mix of biguanide (metformin), DPP4i (sitagliptin) and sulfonylurea (glimepiride).
  • if a rapid increase of blood sugar is found, then some regular insulin might be considered.

701277494

220623

[objective]

  • exam finding
    • 2022-05-10 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Left pneumothorax.
      • Much regression (1.6x5.0cm) of right liver margin metastases.
    • 2022-02-08 Patho - Liver biopsy needle/wedge
      • Liver, CT-guided biopsy - Consistent with metastatic endometroid carcinoma, poorly differentiated
      • IHC: ER (+), PR (focal +), Vimentin (+), and PAX8 (+).
    • 2022-01-29 CT - Lung, mediastinum, pleura
      • Liver surface meta and lung meta. The liver meta progressed.
      • There is no previous chest CT for comparison. the lung meta might be new.
    • 2022-01-11 CT - Liver, spleen, biliary duct, pancreas
      • S/P hysterectomy and oophorectomy.
      • Recurrent/peritoneal carcinomatosis in RUQ (subphrenic region with indentation of liver surface).
      • Subpleural nodule, 0.5cm in LLL.
    • 2021-12-20 MRI - Pelvis
      • S/P hysterectomy and oophorectomy.
      • Irregularity at liver surface (srs11 img11 and 18), carcinomatosis or artifact?
    • 2021-05-20 Patho - uterus neoplastic
      • pathologic diagnosis
        • Uterus, endometrium, staging surgery - Endometrioid carcinoma, grade 3
        • Uterus, myometrium, staging surgery - Involved by tumor ( > 1/2 thickness)
        • AJCC 8th edition Pathology stage: pT1bN0 (If cM0), FIGO IB, pStage IB
      • IHC: ER: positive (90%), PR: positive (90%), CK(+), vimentine(+), p63(+), Napsin A(-)
    • 2021-04-29 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C - poorly differentiated carcinoma
      • ER(+), PR(+), p16(focal +), p63(focal +), and Vimentin(+).
    • 2021-04-23 MRI - Pelvis
      • suspected endometrial malignancy, if proven malignancy, cstage T1bN0M0.
  • consultation
    • 2022-03-02 Urology
      • Q
        • The patient complaints frequent urination at night for 2weeks, so we need your help, thanks a lot!!
      • A
        • I have visit this patient and review the history. She compliant about nocturia for 3 weeks.
        • The possible etiologies including urinary tract infection, overactive bladder or nocturnal polyuria.
        • Please check U/A, U/C first and may treat UTI first as your expertise for at least one week if proved infection.
        • If there’s no evidence about UTI, Detrusitol 1# QD and Minirin 1# HS could be used for the other etiologies if no contraindications.
        • Uro. OPD follow up is indicated. Thanks for your consultation.
  • surgical operation
    • 2021-05-20 ATH + BSO
      • Staging surgery for endometrial cancer.
      • Pathology and cytology pending.
      • Residual tumor: not seen residual tumor.
    • 2021-04-29
      • D&C, diagnostic and theraputic      
      • Endometrial hyperplasia 
  • radiotherapy
    • 2021-06-18 ~ 2021-08-02: 4500cGy/25fx pelvic, 1200cGy/3fx vis IVRT to vaginal cuff mucosa surface.
  • chemotherapy
    • 2021-03-01 ~ ongoing: paclitaxel + carboplatin
    • 2021-06-22 ~ 2021-07-27: cisplatin 6 cycles as part of CCRT.

==========

2022-06-23

  • Following paclitaxel and carboplatin treatment since early March, the CT scan performed on 2022-05-10 showed significant regression of right liver margin metastases.
  • Nocturia complained in late February is no longer in the list of problems.
  • Blood glucose levels were 228 and 224 mg/dL since this hospitalization, and the patient might need to be followed up in order to check whether there is diabetes present.

2022-03-02

  • disease progresses, liver mets has been proved s/p cisplatin-based CCRT (Jun ~ Jul 2021) s/p ATH + BSO (Apr ~ May 2021).
  • the patient just starts receiving paclitaxel + carboplatin during this hospitalization.
  • lenvatinib plus pembrolizumab showed promising antitumor activity in patients with advanced endometrial carcinoma who have experienced disease progression after prior systemic therapy, regardless of tumor MSI status.

701385445

220620

{alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVB}

  • lab data
    • Alkaline phosphatase (34~104)
      • 2022-06-20 300 U/L
      • 2022-06-17 208 U/L
    • LDH (140~271)
      • 2022-06-20 1087 U/L
      • 2022-06-17 838 U/L
    • S-GOT/AST (13~39)
      • 2022-06-20 95 U/L
      • 2022-06-17 45 U/L
      • 2022-06-13 24 U/L
      • 2022-06-09 16 U/L
      • 2022-06-06 20 U/L
      • 2022-06-01 31 U/L
      • 2022-05-29 32 U/L
      • 2022-05-12 48 U/L
    • S-GPT/ALT (<41)
      • 2022-06-20 51 U/L
      • 2022-06-17 15 U/L
      • 2022-06-13 9 U/L
      • 2022-06-09 8 U/L
      • 2022-06-06 13 U/L
      • 2022-06-01 17 U/L
      • 2022-05-29 22 U/L
      • 2022-05-12 54 U/L
    • Albumin (3.5~5.7)
      • 2022-06-20 2.5 g/dL
      • 2022-06-13 2.4 g/dL
      • 2022-06-09 2.5 g/dL
      • 2022-06-01 2.2 g/dL
      • 2022-05-29 2.3 g/dL
      • 2022-05-26 1.9 g/dL
    • Albumin % (54.0~60.3)
      • 2022-05-28 43.3 %
    • 2022-05-28
      • Zinc, Zn 417 ug/L
      • Protein, total 3.8 g/dL
      • Albumin 43.3 %
      • Alpha-1 4.7 %
      • Alpha-2 11.3 %
      • Beta 21.2 %
      • Gamma 19.5 %
      • M-peak Negative
      • A/G Ratio 0.8
    • 2022-05-27
      • Anti-ds DNA Antibody <0.5 IU/ml
      • Anti-ENA SS-A(Ro) 0.6 EliA U/ml
      • Anti-ENA SS-B(La) <0.3 EliA U/ml
    • 2022-05-23
      • Anti-HBs 49.32 mIU/mL
    • 2022-05-17
      • Anti-HBc Reactive 7.40 S/CO
      • AFP 14232.3 ng/mL
  • exam finding
    • 2022-05-31 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Pleura effusion of right and left costal-phrenic angle
      • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • 2022-05-26 Visceral Angiography 2 vessels
      • Tumor enhancement at lower esophagus and stomach. No evidence of active bleeding.
    • 2022-05-26 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal tumor with surface friability, 30cm below the insicor extent to cardia
        • Superficial gastritis
        • Duodenal polyps, bulb
        • Duodenal subepithelial lesion, 2nd portion, suspected lymphatic cyst
      • Suggestion
        • If acitive bleeding, consider angiography for embolization and surgical intervention. Endoscopic treatment is NOT suitable for tumor bleeding. (Hemospray powder was not available in our hospitial)
    • 2022-05-19 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Compatible with AFP-producing carcinoma, poorly differentiated, metastatic
      • The sections show a picture compatible with metastatic AFP-producing carcinoma, poorly differentiated, composed of extensive and nearly total tumor necrosis, with a tiny solid nest of viable polygonal neoplastic cells.
      • IHC, tumor cells reveal: CK7(-), CK20(-), and AFP (scattered tumor cells +). Suggest clinic correlation.
    • 2022-05-19 2D transthoracic echocardiography
      • Dilated LA and aortic root
      • Thickening of IVS and LVPW
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild to moderate MR, mild TR and PR
      • AV sclerosis with mild AR
      • No regional wall motion abnormalities
    • 2022-05-18 Patho - colon biopsy
      • Intestine, large, ascending colon, biopsy — hyperplastic polyp
      • Intestine, large, descending colon, biopsy — hyperplastic polyp
      • Intestine, large, sigmoid colon, biopsy — hyperplastic polyp
    • 2022-05-17 CT - liver, spleen, biliary duct, pancreas
      • Imaging Report Form for Esophageal Carcinoma
        • Large esophageal tumor with GE junction invasion, lymph nodes metastsais. Liver tumors, suspected liver metastasis. cstage T4N2M1.
        • Left pleural effusion. Bilateral basal lung atelectasis.
    • 2022-05-16 Abdominal Ultrasonography
      • Diagnosis
        • liver tumors: suspected HCC, or metastatic tumors
        • liver hyperechoic tumor, S1: suspected hemangioma
        • liver parenchymal disease
        • mild gallbladder wall thickening
      • Suggestion
        • 4 phase CT or dynamic MRI study
    • 2022-05-13 Patho - esophageal biopsy
      • Esophagus, middle to lower, biopsy — Poorly differentiated adenocarcinoma
      • Section shows pieces of solid sheets and glandular tumor cells infiltrating in fibrous tissue.
      • The immunohistochemical stains reveal CK(+), CK7(-), CK20(-), CK5/6(-), p40(-), CDX2(+), TTF-1(equivocal), Napsin A(-), CD56(-), and PSA(-). The results are in favor of poorly differentiated adenocarcinoma.
      • Addendum: The immunohistochemical stains reveal alpha-fetoprotein (focal +), Hepatocyte(equivocal), Arginase (-), and Her-2/neu (Ab): Negative (0). The results are in favor of gastric or esophageal primary tumor.
    • 2022-05-12 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal tumor, 30cm below the insicor extent to cardia, s/p biopsy
        • Superficial gastritis
        • Duodenal polyps, bulb
        • Duodenal subepithelial lesion, 2nd portion, suspected lymphatic cyst
      • Suggestion
        • Pursue biopsy result
  • consultation
    • 2022-05-25 Radiation Oncology
      • Under the impression of Adenocarcinoma of M-L/3 esophagus, with liver metastases, cT4N2M1, with active tumor bleeding, palliative RT is indicated. CT-simulation will be arranged today. Plan to deliver 40 Gy/ 20 fx to the M-L/3 esophageal tumor.
    • 2022-05-25 Hemato-Oncology
      • Impression:
        • Alpha-fetoprotein producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVb
        • Anemia, subacute GI bleeding related
        • Fever, suspect transfusion reaction, mix with infection and tumor fever
        • Staphylococcus aureus bacteremia
        • Hypertension
      • Suggestion:
        • We wound like to take over this case if you agree
        • Consult radio-oncologist for CCRT
        • Arrange port A insertion
        • CCRT is indicated for esophagus cancer local tumor bleeding control and followed by palliative chemotherapy for metastasis disease
        • Add entecarvir for chemotherapy HBV flare up prophylaxis (Anti-Hbc positive)
        • LPRBC to keep Hb>=8, May consider give vena before blood transfusion (history of suspect transfusion reaction)
        • Check Ca for frequent blood transfusion
        • Pending anemia survey (Fe, TIBC, Ferrtin, folic acid, vitamin B12). May also check serum EP, TSH, Freee T4, ANA, C3, C4, Anti-dsDNA, RF, Anti-Ro/Anti-La)
        • Thanks for your consultation. If there is any problem, please feel free to let us known.
    • 2022-05-18 Infectious Disease
      • Q
        • Intermittent fever occur, 20220515 blood culture was showed Staphylococcus aureus (OSSA), we need your exerpance assessment the infcetion source and advice, thnak you~
      • A
        • Antibiotcs with stazilin 1g iv q8h is suggested for OSSA bacteremia.
        • Please arrange CV-echo.
        • F/u B/C 3 days later.
  • radiotherapy
    • 2022-05-25 ~ undergoing - M-L/3 esophageal tumor 32 Gy/ 16 fx.
  • chemoimmunotherapy
    • 2022-06-01 ~ undergoing - FOLFOX6

[memo]

  • Pathology IHC results
    • Esophageal biopsy pathology (2022-05-13) IHC revealed CK(+), CK7(-), CK20(-), CK5/6(-), p40(-), CDX2(+), TTF-1(equivocal), Napsin A(-), CD56(-), PSA(-), alpha-fetoprotein(focal +), Hepatocyte(equivocal), Arginase(-), Her-2/neu(Ab): Negative(0).
    • Liver biopsy pathology (2022-05-19) IHC revealed CK7(-), CK20(-), and AFP (scattered tumor cells +).
  • CK7−/CK20− could mean ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5923363/ )
    • Prostate adenocarcinoma
    • Renal (clear cells)
    • Hepatocellular carcinoma
    • Adrenocortical carcinoma
    • Non-seminoma germ cell tumours
    • Mesothelioma
    • Small cell lung carcinoma
    • Gastric adenocarcinoma
  • Oesophagus: CDX2+/−, CEA+, CDH17+, MUC1−/+, MUC5AC−/+, SATB2−
  • Liver: HepPar1+, CD10+, pCEA+, mCEA−, AFP+, Glypican-3+, Arginase-1+, CK19−

[assessment]

  • This is a 57 y/o male was diagnosed with alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis in May 2022, T4N2M1 stage IVB, and has been receiving CCRT with FOLFOX6 regimen since late May 2022.
  • The liver enzyme levels have been rising for the last two weeks which should be addressed while daily Baraclude (entecavir) 0.5mg has been prescribed since a recent OPD visit on 2022-06-17.
    • S-GOT/AST (13~39)
      • 2022-06-20 95 U/L
      • 2022-06-17 45 U/L
      • 2022-06-13 24 U/L
      • 2022-06-09 16 U/L
    • S-GPT/ALT (<41)
      • 2022-06-20 51 U/L
      • 2022-06-17 15 U/L
      • 2022-06-13 9 U/L
      • 2022-06-09 8 U/L
    • ALT/AST ratio
      • 2022-06-20 1.86
      • 2022-06-17 3.00
      • 2022-06-13 2.66
      • 2022-06-09 2.00
  • Hypoproteinemia, which is unlikely to be caused by proteinuria (2022-06-20 blood creatinine 0.57 mg/dL, eGFR 156.60) could be the result of malnutrition? or probably the result of impaired protein synthesis due to liver mets.
    • Albumin
      • 2022-06-20 2.5 g/dL
      • 2022-06-13 2.4 g/dL
      • 2022-06-09 2.5 g/dL
      • 2022-06-01 2.2 g/dL
      • 2022-05-29 2.3 g/dL
      • 2022-05-26 1.9 g/dL
  • After correction for hypoalbuminemia, serum calcium falls within normal range (2.3 mmol/L). ( https://www.mdcalc.com/calcium-correction-hypoalbuminemia , based on unadjusted Ca 1.96 mmol/L, normal albumin 4 g/dL)

700983554

220617

  • exam finding
    • 2022-06-15 CXR
      • Enlargement of right hilum.
    • 2022-06-15 EKG
      • Sinus tachycardia
    • 2022-02-24 SONO - neck (lymph node)
      • Sonography of neck revealed some LNs in bil. neck.
    • 2021-12-02 Patho - bone marrow biopsy
      • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with partial remission
      • The sections show hypercellular marrow (80%). The M/E ratio about 8:1 in CD71 immunostain. Both granulocytic and megakaryocytic proliferation with occasional small megakaryocytes are present. Clusters of MPO+ myeloid cells(30%) and CD68+ monocytes (15%) can be identified. Scattered CD34+ and/or CD117+ blasts,constitue 10% of marrow cells are evident. The finding is compatible with acute myeloid leukemia with partial remission. Suggest bone marrow smear evaluation and clinic correlation.
    • 2021-11-15 Patho - soft tissue nontumor/mass/lipoma/debridement
      • Skin, right groin, excisional biopsy — Acute leukemia involvement
        • Microscopically, it shows skin tissue with marked infiltration of leukemic tumor cells in the dermis with focal necrosis. The tumor cells show nuclear hyperchromasia, plemorphism, coarse chromatin, prominent nucleoli and high N/C ratio.
      • Skin, left groin, excisional biopsy — Acute leukemia involvement
        • Microscopically, it shows skin tissue with marked infiltration of leukemic tumor cells in the dermis. The tumor cells show nuclear hyperchromasia, plemorphism, coarse chromatin, prominent nucleoli and high N/C ratio.
      • Skin, left thigh, excisional biopsy — Acute leukemia involvement
        • Microscopically, it shows skin tissue with ulceration, focal necrosis, hemorrhage and dense infiltration of leukemic tumor cells.
        • Immunohistochemical stain reveals MPO(+), CD10(focal+), CD117&CD34(+, 25%), TdT(-), CD20(focal+, <5%), CK(-), CD3(+, 5%), CD138(+, <5%), Bcl-2(+), Bcl-6(+), cyclin d1(-).
    • 2021-09-14 EKG
      • Sinus tachycardia
    • 2021-09-13 2D Transthoracic Echocardiography
      • Dilated LA
    • 2021-09-01 CT - abdomen, pelvis
      • FINDINGS:
        • There is splenomegaly and the greatest anterior-posterior dimention measuring 14.7 cm.
        • There are multiple variable sized enlarged lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, mesentery, and bilateral inguinal area. please correlate with clinical condition.
        • A hepatic cyst measuring 0.5 cm in S4 is suspected. Please correlate with sonography.
      • IMP:
        • Splenomegaly.
        • There are multiple variable sized enlarged lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, mesentery, and bilateral inguinal area.
    • 2021-09-01 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — acute leukemia.
      • IHC stains: CD117: 30%; CD34: 30 %; MPO: 20-30%, LCA: 50-60%; CD10: <10% (of the nucleated cells). Please correlate with other laboratory results such as one marrow smear, hemogram, and flow cytometry.
      • Section shows piece(s) of bone marrow with 70% cellularity and M:E ratio of approximately 4:1. Three cell lineages are present with left shift of leukocytes, inculding many immature leukocytes, many lymphocytes, plasma cell and eosinophils. Megakaryocytes are adequate in number.
    • 2021-08-31 EKG
      • Sinus tachycardia
    • 2019-04-12 EKG
      • Sinus tachycardia
      • Rightward axis
      • Borderline ECG
  • consultation
    • 2011-11-11 Plastic and Reconstructive Surgery
      • Q
        • This 41-year-old man has
          • Acute myeloblastic leukemia
          • AIDS under Atripla
          • Left dorsal foot cellulitis with ulcer and left medial thigh ulcer
          • Latent syphilis.
        • He is admitted to recieve target therapy for acute myeloblastic leukemia.
          • After admission, blood examination revealed WBC:303.62 10^3/uL, Hb: 4.9 g/dL, Plt: 96 10^3/uL, Band 2%, Neurophil: 0%, Blast: 87.0, and Uric acid: 9.2mg/dL.
          • Blood trasfusion with pack-RBC 4U and LPR 2U were given. Normal saline 1500ml and 1.5mg Rasburicase were administered to correct his uric acid.
          • Blood test today morning showed improvement and the treatment will be continued.
          • Bilateral inguinal masses 7x7cm were discovered. The masses are hard, round, elevated, and mildy pigmented. Tenderness was also noted.
        • Due to the bilateral inguinal masses, we would like to consult you for arranging I&D or other appropriate management for the patient. Thank you very much.
      • A
        • 41 y/o male patient
          • Right groin mass with partial necrosis
          • Left groin mass
          • Left thigh mass
        • A
          • underlying history: Acute myeloblastic leukemia, AIDS under Atripla, Latent syphilis.
          • I had visited the patient and explained to him and his father, the patient reported that these masses gradually enlarged within 1 month.
          • Those masses were hard, firm and non-movable without obvious infectoin sign.
          • The tumor border was ill-defined.
          • Partial necrosis of the tumor was suspected.
          • The possibility of malignant tumor was informed.
          • It’s not possible nor suitable for complete excision.
          • Tissue proof first is recommended
        • Plan
          • We will arrange biopsy of these 3 lesions and debridement of right groin area next Monday
    • 2021-09-02 Infectious Disease
      • Q
        • For advice on antibiotics for new onset of fever in an HIV patient with leukemia.
          • This is a 40 year old man who admitted to the hospital for the treatment of acute leukemia.
          • He had underlying HIV infection and was previously seen at your OPD. This time during hospitalization, he was found to have elevated levels of TPHA and RPR/VDRL titers.
          • On 20210902, his body temperature was elevated up to >38 C and elevated level of WBC but did not complain of any discomfort in particular.
        • Please kindly assist to evaluate the patient and advise us on the management of the condition. Thank you.
      • A
        • Assessment
          • 40-year-old HIV infection male patient, with loss of follow up with HAART (Highly Active Antiretroviral Therapy) for two years, now admitted due to acute leukemia.
          • No HIV viral load data is available, CD4 count up to 2905, leukemoid reaction related, white count high to 52800.
          • Besides HIV infection, he had received 3-dose penicillin injection in Jan 2018, and now syphilis RPR titer is high to 128.
          • Benzathin penicillin retreatment is necessary.
          • HAART with Atripla has been restarted since yesterday.
        • Suggestion
          • continue Atripla.
          • Benzathin penicillin injection with 2.4 million units IM once a week for 3 weeks.
          • Follow up RPR titer 3 months later.
    • 2021-08-31 General and Gastroenterological Surgery
      • Q
        • for on port-a
        • this is a 40-year-old male who has the history of human immunodeficiency virus and the INF follow-up, Atripla using since 2017 until 2019, due to the viral load <20, CD4:1046.
        • this time, he is admitted for ALL chemotherapy treatment, so we need your help for on port-a, think a lot!!
      • A
        • we will arrange port-A implantation this w4
  • lab data
    • HIV 1 Viral Loads
      • 2022-04-15 83.2 copies/mL
      • 2022-01-17 30.1 copies/mL
      • 2021-09-08 29100 copies/mL
    • HIV-1 RNA
      • 2019-08-23 <20 copies/mL
      • 2019-02-01 <20 copies/mL
      • 2018-11-09 37 copies/mL
      • 2018-05-11 <20 copies/mL
      • 2018-02-09 191 copies/mL
    • HIV Ab EIA (enzyme immunoassay)
      • 2021-09-01 Reactive
      • 2018-01-03 Reactive
    • CD3+∕CD4+ Helper T
      • 2022-04-12 46.7 % 593 /uL
      • 2022-01-12 45.8 % 1195 /uL
      • 2021-09-01 32.9 % 2905 /uL
      • 2019-08-22 40.4 % 1345 /uL
      • 2019-01-30 38.0 % 1046 /uL
      • 2018-11-07 37.1 % 1161 /uL
      • 2018-05-09 35.5 % 980 /uL
      • 2018-02-07 32.9 % 880 /uL
    • CD3+∕CD8+ Suppressor T
      • 2022-04-12 44.5 % 565 /uL
      • 2022-01-12 44.4 % 1160 /uL
      • 2021-09-01 50.6 % 4459 /uL
      • 2019-08-22 37.9 % 1260 /uL
      • 2019-01-30 40.3 % 1108 /uL
      • 2018-11-07 40.8 % 1277 /uL
      • 2018-05-09 44.7 % 1233 /uL
      • 2018-02-07 48.9 % 1310 /uL
    • CD4/CD8 Ratio
      • 2022-04-12 1.0 Ratio
      • 2022-01-12 1.0 Ratio
      • 2021-09-01 0.7 Ratio
    • CD3 T Cells
      • 2022-04-12 92.3 %
      • 2022-01-12 91.6 %
      • 2021-09-01 79.4 %
      • 2019-08-22 80.5 %
      • 2019-01-30 80.4 %
      • 2018-11-07 79.2 %
      • 2018-05-09 83.2 %
      • 2018-02-07 84.5 %
    • CD19 B Cells
      • 2022-04-12 1.4 %
      • 2022-01-12 3.0 %
      • 2021-09-01 7.7 %
      • 2019-08-22 10.0 %
      • 2019-01-30 10.3 %
      • 2018-11-07 10.6 %
      • 2018-05-09 9.1 %
      • 2018-02-07 6.2 %
    • CD16+56 NK
      • 2021-09-01 8.9 %
    • CMV viral load assay
      • 2021-10-08 Target not deteceted IU/mL
      • 2021-09-06 Target not deteceted IU/mL
    • CMV IgG
      • 2021-09-01 Reactive 1,201.3 AU/mL
    • CMV IgM
      • 2021-09-01 Nonreactive 0.10 Index
    • TPHA (Treponema Pallidum Hemagglutination Assay)
      • 2022-04-12 Reactive 1: 5120
      • 2021-09-01 Reactive >1:20480
      • 2018-11-08 Reactive 1: 5120
      • 2018-05-21 Reactive 1: 5120
    • RPR/VDRL (Rapid Plasma Reagin / Veneral Disease Research Laboratory test)
      • 2022-04-12 Reactive 1: 64
      • 2021-09-01 Reactive 1:128
    • STS-RPR (Serological Test for Syphilis - Rapid Plasma Reagin)
      • 2018-11-07 Reactive 1: 4
      • 2018-05-21 Reactive 1: 4
      • 2018-01-03 Reactive 1:64
    • Procalcitonin (PCT)
      • 2022-06-15 1.29 ng/mL
      • 2022-03-23 0.64 ng/mL
      • 2021-11-15 0.65 ng/mL
      • 2021-11-12 0.52 ng/mL
      • 2021-10-07 0.40 ng/mL
      • 2021-10-04 0.37 ng/mL
      • 2021-09-27 0.64 ng/mL
      • 2021-09-20 0.60 ng/mL
      • 2021-09-06 0.39 ng/mL
      • 2021-09-01 0.26 ng/mL
    • CRP (C-reactive protein)
      • 2022-06-16 12.35 mg/dL
      • 2022-06-15 17.87 mg/dL
      • 2022-03-23 6.08 mg/dL
      • 2022-03-18 8.13 mg/dL
      • 2021-12-20 1.73 mg/dL
      • 2021-12-18 0.84 mg/dL
      • 2021-12-16 0.94 mg/dL
      • 2021-12-14 1.42 mg/dL
      • 2021-12-12 2.45 mg/dL
      • 2021-12-10 0.92 mg/dL
      • 2021-12-08 0.90 mg/dL
      • 2021-12-06 1.06 mg/dL
      • 2021-12-03 1.13 mg/dL
      • 2021-12-01 1.33 mg/dL
      • 2021-11-30 1.91 mg/dL
      • 2021-11-29 1.87 mg/dL
      • 2021-11-27 1.90 mg/dL
      • 2021-11-25 2.44 mg/dL
      • 2021-11-24 4.03 mg/dL
      • 2021-11-23 5.19 mg/dL
      • 2021-11-22 3.43 mg/dL
      • 2021-11-19 4.70 mg/dL
      • 2021-11-18 5.63 mg/dL
      • 2021-11-17 7.42 mg/dL
      • 2021-11-16 8.85 mg/dL
      • 2021-11-15 7.62 mg/dL
      • 2021-11-14 6.37 mg/dL
      • 2021-11-12 5.53 mg/dL
      • 2021-11-11 3.69 mg/dL
      • 2021-11-10 4.15 mg/dL
      • 2021-09-27 5.71 mg/dL
      • 2021-09-22 4.78 mg/dL
      • 2021-09-20 7.14 mg/dL
      • 2021-09-14 10.05 mg/dL
      • 2021-09-08 2.03 mg/dL
      • 2021-09-06 7.04 mg/dL
      • 2021-09-01 3.78 mg/dL
      • 2021-08-31 3.62 mg/dL
      • 2019-08-22 0.49 mg/dL
      • 2018-12-16 8.26 mg/dL
      • 2018-02-07 1.34 mg/dL
  • chemoimmunotherapy
    • AML
      • 2022-06-16 azacitidine 75mg/m2 for 7 days
      • 2022-03-18 azacitidine 75mg/m2 for 7 days
      • 2021-11-22 azacitidine 75mg/m2 for 7 days
    • HIV
      • 2021-09-08 ~ ongoing - Atripla (efavirenz 600mg + emtricitabine 200mg + tenofovir 300mg) HS PO
      • 2018-01-10 ~ 2019-08 - Atripla (efavirenz 600mg + emtricitabine 200mg + tenofovir 300mg) HS PO

[assessment]

  • Sinus tachycardia has been observed for over 12 months (EKG 2022-06-15, 2021-09-14, 2021-8-31, 2021-04-21).

700202562

220614

{multiple myeloma}

  • exam finding
    • 2022-05-09 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Plasma cell myeloma
      • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.1 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for sections after short decalcification.
      • The sections show a picture of plasma cell myeloma, composed of hypocellular marrow (45%) for her age. Interstitial distribution of plasma cells, comprised 10-20% nucleated cells in CD138 immunostain. The plasam cells also show lambda light chain restriction. M/E ratio about 1/4~5, hyperplasia of erythroid and hypoplasia of myeloid series, hyperplastic megakaryocytes with focal mononucleation and hyposegmentation and no increase of blast, which highlights by CD61, CD71, CD34, CD117 and MPO immunostains. Follow up.
    • 2021-12-30 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — myeloma.
      • IHC stains: CD117: <2%; CD34: <2 %; MPO: <5%, CD71: 10-20 %, CD138: 70-80%, and light chain of kappa and lambda show a predominant lambda sub-population. (of the nucleated cells).
      • Specimen submitted in formalin consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 1.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
      • Section shows piece(s) of bone marrow with 70% cellularity and M:E ratio of approximately 5:1. Three cell lineages are present with a predoimant plasmcytoid cells. Megakaryocytes are adequate in number.
  • lab data
    • Hematopoietic Progenitor Cell (HPC) Ratio
      • 2022-05-31 0.20 %
      • 2022-05-30 0.33 %
    • CD45 + Total leukocyte
      • 2022-05-31 309430 /uL
      • 2022-05-31 55666 /uL
      • 2022-05-30 372040 /uL
    • CD34+ Count
      • 2022-05-31 4940 /uL
      • 2022-05-31 102 /uL
      • 2022-05-30 8140 /uL
    • %CD34+
      • 2022-05-31 1.60 %
      • 2022-05-31 0.18 %
      • 2022-05-30 2.19 %
    • WBC
      • 2022-05-31 62.43 *10^3/uL
      • 2022-05-31 65.69 *10^3/uL
      • 2022-05-30 56.24 *10^3/uL
      • 2022-05-30 54.79 *10^3/uL
      • 2022-05-29 21.76 *10^3/uL
      • 2022-05-28 4.57 *10^3/uL
      • 2022-05-26 3.07 *10^3/uL
      • 2022-05-25 7.57 *10^3/uL
      • 2022-05-23 21.61 *10^3/uL
      • 2022-05-19 7.44 *10^3/uL
      • 2022-04-22 18.42 *10^3/uL
      • 2022-04-15 10.56 *10^3/uL
      • 2022-04-01 12.93 *10^3/uL
      • 2022-03-25 8.36 *10^3/uL
      • 2022-03-11 9.42 *10^3/uL
      • 2022-03-04 6.47 *10^3/uL
      • 2022-02-18 12.45 *10^3/uL
      • 2022-02-11 4.78 *10^3/uL
      • 2021-12-22 5.68 *10^3/uL
    • HGB
      • 2022-05-31 9.9 g/dL
      • 2022-05-31 10.4 g/dL
      • 2022-05-30 10.2 g/dL
      • 2022-05-30 10.8 g/dL
      • 2022-05-29 11.6 g/dL
      • 2022-05-28 11.4 g/dL
      • 2022-05-26 10.8 g/dL
      • 2022-05-25 11.2 g/dL
      • 2022-05-23 12.4 g/dL
      • 2022-05-19 12.9 g/dL
      • 2022-04-22 11.3 g/dL
      • 2022-04-15 12.0 g/dL
      • 2022-04-01 11.2 g/dL
      • 2022-03-25 10.8 g/dL
      • 2022-03-11 10.2 g/dL
      • 2022-03-04 9.4 g/dL
      • 2022-02-18 9.0 g/dL
      • 2022-02-11 8.8 g/dL
      • 2021-12-22 8.7 g/dL
    • PLT
      • 2022-05-31 73 *10^3/uL
      • 2022-05-31 93 *10^3/uL
      • 2022-05-30 131 *10^3/uL
      • 2022-05-30 153 *10^3/uL
      • 2022-05-29 198 *10^3/uL
      • 2022-05-28 230 *10^3/uL
      • 2022-05-26 289 *10^3/uL
      • 2022-05-25 348 *10^3/uL
      • 2022-05-23 408 *10^3/uL
      • 2022-05-19 420 *10^3/uL
      • 2022-04-22 482 *10^3/uL
      • 2022-04-15 354 *10^3/uL
      • 2022-04-01 413 *10^3/uL
      • 2022-03-25 424 *10^3/uL
      • 2022-03-11 394 *10^3/uL
      • 2022-03-04 319 *10^3/uL
      • 2022-02-18 329 *10^3/uL
      • 2022-02-11 290 *10^3/uL
      • 2021-12-22 303 *10^3/uL
  • chemoimmunotherapy
    • 2022-05-19 cyclophosphamide 2500mg/m2
    • 2022-02-11 ~ 2022-04-22 - bortezomib 1.3mg/m2 (day 4, day 7) (8 times) within VTD (bortezomib + thalidomide + dexamethasone)

700841543

220613

{gastric cancer with colon mets s/p subtotal gastrectomy and partial T-colectomy}

[subjective]

  • 2020-08-03
    • fasting epigastric discomfort for 1-2 weeks
    • fullness(-), nausea(-)
  • 2021-04-14
    • epigasrtalgia for for 2-3 months
    • mild response to strocain and h2 blocker from other hopsital but still discomfort
    • hunger pain (+) improving after intake

[objective]

  • exam finding
    • 2022-06-11 CT - abdomen, pelvis
      • S/P gastric operation. Small bowel ileus with massive ascites.
      • Bil. liver cysts (up to 2.6cm).
    • 2022-05-09 Abdomen - standing (diaphragm)
      • Presence of ileus.
    • 2022-05-09 Abdominal Ultrasonography
      • suspected liver parenchymal disease
      • liver cysts
      • pancreas obscured
      • spleen obscured
      • ascites: moderate to large amount
    • 2022-04-22 CT - lung/mediastinum/pleura
      • s/p partial gastrectomy with massive ascites. Stationary.
      • regression of right lower lobe opacity, previous infection is favored.
    • 2022-04-14 CT - abdomen, pelvis
      • Gastric cancer s/p operation. Massive ascites. Small bowel ileus.
      • A patchy density (1.7mm) at RLL.
    • 2022-01-14 CT - abdomen, pelvis
      • s/p subtotal gastrectomy
      • there are several hepatic cysts in both lobes and the largest one 2.2 cm in size
    • 2021-10-07 CT - abdomen, pelvis
      • Gastric cancer s/p operation.
      • A nodule (3.7mm) at LUL.
    • 2021-10-05 CXR
      • Blurring of right heart border is noted.
    • 2021-06-21 Standing KUB; 2021-06-18 KUB
      • Small bowel obstruction is suspected. Please correlate with contrast enhanced CT.
      • S/P ileostomy? please correlate with clinical condition.
    • 2021-05-25 Small bowel series
      • Dilatation of proximal small bowel. Collapse of distal ileum and colon
      • The transmit time is less than 24 hours.
    • 2021-05-07 patho - stomach subtotal/total (tumor)
      • pathologic diagnosis
        • Stomach, subtotal gastrectomy — Poorly cohesive carcinoma (signet-ring cell carcinoma)
        • Lymph nodes, LN dissection — Metastatic carcinoma (3/32)
        • AJCC Pathologic staging — pT4aN2M1, stage IV
      • microscopic examination
        • Histologic type: Poorly cohesive carcinoma, signet-ring cell type (signet-ring cell carcinoma) (Lauren classification: diffuse type)
        • Histologic grade: Poorly differentiation (G3)
        • Depth of tumor invasion: Tumor invades the serosa
        • Margins: Free; Distance from closest margin: 3 mm (radial margin)
        • Perineural invasion: Present
        • Lymphovascular space invasion: Present
        • Regional lymph nodes: Metastatic carcinoma (3/32)
        • Extracapsular extension: Absent
        • Omentum: Free of tumor invasion
        • Additional pathologic findings: Metastatic carcinoma of T-colon (S2021-07224)
        • Pathologic Staging: pT4aN2M1; Stage IV
        • IHC (S2021-06134): HER2(-), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • 2021-05-07 patho - colon segmental resection for tumor
      • Transverse colon, partial resection — Poorly cohesive carcinoma (signet-ring cell carcinoma), metastatic
      • Histology Grade: Poorly differentiated
    • 2021-04-29 CT - whole abdomen, pelvis
      • imaging stage: T1aN0M0, stage I.
    • 2021-04-20 patho - stomach biopsy
      • greater curvature side of lower body - adenocarcinoma.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
    • Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade B
        • Esophageal phlebectasia, lower esophagus
        • Gastric ulcer, GC, lower body, s/p Bx
        • Atrophic gastritis, antrum
      • Suggestion:
        • Pending Bx and CLO
        • PPI tx
  • lab data
    • CA125
      • 2022-05-16 114.7 U/mL
      • 2022-04-25 95.9 U/mL
      • 2022-04-18 139.0 U/mL
      • 2022-03-14 157.8 U/mL
      • 2022-02-19 102.4 U/mL
      • 2022-01-11 31.0 U/mL
      • 2021-12-21 17.7 U/mL
      • 2021-11-16 19.9 U/mL
      • 2021-10-06 18.7 U/mL
      • 2021-09-06 31.5 U/mL
      • 2021-08-27 26.7 U/mL
      • 2021-07-27 34.5 U/mL
  • consultation
    • 2021-06-23 Infectious disease
      • This 64-year-old man patient is a case of Gastric cancer with lymph nodes metastasis s/p subtotal gastrectomy with T-colectomy and D2+ lymph node dissection, pT4aN2M1, stage IV. Chemotherapy with FOLFOX (Oxalip 65mg/m2, LV 400mg/m2, 5FU 2400mg/m2) on 2021/06/16~2021/06/18. IP chemotherapy with 5FU(400mg/m2) + Gentamycin 40mg + Rolikan 40ml on 2021/06/16. Abdominal pain with Peritonitis with ascites/C showed Acinetobacter ursingii and Candida parapsilosis bacteria. Abdominal pain improving after antibiotic with Flumarin 1000mg iv q8h since 2021/06/18. Now, for evaluate antibiotic therapy for ascites/C showed Acinetobacter ursingii and Candida parapsilosis bacteria.
      • Antibiotics with tapimycin 4.5g iv q8h and diflucan 200mg iv qd is suggested.
  • surgical operation
    • 2021-05-06 surgery
      • subtotal gastrectomy with LN 1,3,4,5,6,7,8,9,110,12a and 14v dissection
      • partial T-colectomy
      • IPCT with Mitomycin C 25mg/m2(42mg) for 2 hrs
  • radiotherapy
    • 2021-10-25 ~ 2021-11-26 - completed RT to the preOP tumor bed and adjacent lymphatic drainage area: 45 Gy/ 25 fx
  • chemotherapy
    • 2021-12-07 ~ 2022-03-15 - FOLFOX (6 times)
    • 2021-10-26 ~ 2021-11-23 - 5-Fu (4 times), CCRT
    • 2021-06-16 ~ 2021-10-07 - FOLFOX (6 times)
    • 2021-05-07 - 5-Fu 500mg/m2(839mg) day 1~5, leucovorin 34mg day 1, gentamicin
    • 2021-05-06 - mitomycin-C, gentamicin

==========

2022-06-13

  • The patient presented to the emergency department (2022-06-11) with symptoms of severe upper abdominal pain (VAS 9, 3 days of on and off abdominal pain with yellow vomitus once per day). Small bowel obstruction has been listed as an active problem since his admission.
  • Previously, small bowel obstruction was noted on KUB 2021-06 and Small Bowel Series 2021-05-25, which showed proximal small bowel dilatation and collapse of the distal ileum and colon.
  • Proximal small bowel obstruction (duodenum, proximal jejunum) can cause severe nausea and vomiting; as a result, patients typically cease taking in food or liquids orally.
  • Gaslan (dimethylpolysiloxane) 40mg TID PO and Mopride (mosapride citrate) 5mg TID PO have been prescribed since 2022-06-06.
  • In the past few weeks, ascites and pitting edema have been observed; if the condition persists, some diurectics might be helpful.
  • Heart rate 90 -> 120 on 2012-06-12, please keep monitoring the state of hemodynamics.
  • All the oral drugs in active prescription can be administered with nasogastric tube.

2021-08-27

  • recent lab data unremarkable, liver and kidney functions no abnormality, overall not bad.
  • 2021-08-27 around 10:30 visiting the patient (accompanied by his wife)
    • he felt soreness/ache (not pain) in his left arm during the first 30min when premedication being administrated in last three hospitalization. rule out left arm compression or cruch caused symptom. cause remains unknown.
    • mild oral mucosa damage, some triamcinolone acetonide oral ointment (nincort or oralog, the former is available now) for local treatment might be of help.
    • mild diarrhea, not often, could be monitored with PRN antidiarrheal agent e.g. loperamide (2mg/cap is available now)

701350720

220613

  • exam finding
    • 2022-05-27 MRI - brain
      • Finding
        • Mild increases in the size of the enhacning nodular lesions identified in previous MTI on 20220420.
        • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
        • No midline shift, nor mass effect.
        • Focal T1 and T2 hypintensity lesion in right temporal skull, r/o hemangioma. Stationary as compared with MRI on 20220304.
        • Mottled T2-hyperintensity in left pooly aerated mastoid, indicating mastoiditis.
      • IMP: Multiple brain metasases. Mild progression as comapred with MRI on 20220420.
    • 2022-05-26 CT - lung/mediastinum/pleura
      • Findings
        • Chest:
          • Soft tissue mass at left lower lobe up to 4.cm in largest dimension with attachment with left hemithorax is found.
          • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
          • Enlarged left thyroid up to 4.6cm in largest dimension. Stable.
          • There is bilateral pleural effusion.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered. In progression.
          • One fillling defect is found at right pulmonary trunk is found. Pulmonary embolism is considered.
        • Visible abdomen:
          • Low density lesions are found at both lobes of liver is found. In comparison with CT dated on 2022-03-03, the lesions are stationary.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • Left lower lobe lung cancer with stationary size.
        • However, the bone meta and liver meta progressed.
        • Right pulmonary embolism is also noted. Suggest further treatment.
    • 2022-04-20 MRI - brain
      • Findings
        • No remarkable finding of cerebrospinal fluid spaces.
        • A total of 5 enhancing dots at subcortical region at bilateral frontal lobes, left parietal lobe, left occipital lobe and left basal ganglion. Multiple brain metasatses are considered.
        • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
        • No midline shift, nor mass effect.
        • Focal T1 and T2 hypintensity lesion in right temporal skull, r/o hemangioma. Stationary as compared with MRI on 20220304.
        • Mottled T2-hyperintensity in left pooly aerated mastoid, indicating mastoiditis.
      • IMP: Multiple brain metasases as described. Progressive change as comapred with MRI on 20220304.
    • 2022-04-14 CT - lung/mediastinum/pleura
      • Findings
        • Chest:
          • Nodular lesion at left thyroid up to 5.1cm in largest dimension is found. Stationary.
          • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
          • Lobulated mass at left lower lobe up to 3.1cm in largest dimension is found. In comparison with CT dated on 2022-03-03, the lesion regressed.
          • Spiculated nodule at left upper lobe up to 1.04cm is found. Stable.
          • No evidence of bilateral pleural effusion.
          • Small lymph nodes are found in the mediastinum.
          • Tiny nodular lesion at right lower lobe up to 0.2cm in largest dimension.
        • Visible abdomen:
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Nodular lesion at S7 of liver up to 0.8cm in largest dimension is found.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • LEFT LOWER LOBE mass with left upper lobe and right lower lobe lung meta and bone meta. In regression.
        • Left thyroid mass. 5.1cm
    • 2022-03-04 MRI - brain
      • Findings
        • No remarkable finding of cerebrospinal fluid spaces.
        • A small intra-axial enhancing dot at corticomedullary juction region of left anterior frontal lobe, much maller than that on 20220112 MRI.
        • A new enhancing dot at corticomedullary juction region of left posterior frontal lobe. suspected metastasis.
        • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
        • No midline shift, nor mass effect.
        • Focal T1 and T2 hypintensity lesion in right tmeporal skull, suspected hemangioma. Stationary as compared with MRI on 20210112.
        • No remarkable finding of bilateral orbital contents and optic nerves.
        • No remarkable finding of nasopharynx visible in these images.
        • Mottled T2-hyperintensity in left pooly aerated mastoid, indicating mastoiditis.
        • Diffuse mild mucosal thickening in bilateral paranasal sinsues, indicating chronic paranasal sinusitis.
      • IMP:
        • Regression of the metasattic lesion at left frontal lobe.
        • However, a suspicious metastatic lesion appears at left posterior frontal lobe.
    • 2022-03-03 CT - lung/mediastinum/pleura
      • Findings
        • Chest:
          • Thyroid nodule at left side up to 4.6cm in largest dimension.
          • S/p port-A placement with its tip at Superior vena cava.
          • Cavitatory lesion at left lower lobe up to 3.4cm in largest dimension. Reactive pleural effusion is found. In comparison with CT dated on 2022-01-13, the tumor regressed in size.
          • Diffuse Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Diffuse tiny nodules scattered at both lungs is found. Lung meta is considered. In regression.
          • One spluclated nodule at left upper lobe up to 9.5mm in largest dimension. stable.
          • Chains of lymph nodes are found at AP window and subcarinal region. Stationary.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • Left lower lobe lung cancer with mediatinal lymphadenopathy, bilateral lung meta, bone meta.
        • The ovarall tumor extension and size are in regression.
        • Right Thyroid nodule. Suggest follow up.
    • 2022-02-25 MRI - T-spine
      • Findings
        • Numerous enhancing lesions involving every vertebral body of thoracic spine, causing vertebral body compression and spinal canal stenosis due to extensive soft tissue mass, most svere at T3-4 and T9-10 with cord compression and ill-defined intramedullary T2-hyperintensity.
        • Multiple metastatic lesions in bialetrla ribs.
        • A huge soft tissue tumor in left lower lung, with left pleural effusion.
        • Several T2-hyperintense lesions in right lobe of liver. D/D: metastases or cysts. -IMP:
        • C/W lung cancer with diffuse bony metastases in ribs and thoracic spine (with compressive myelopathy at T3-4 and T9-10 levels).
    • 2022-01-09 Tc-99m MDP whole body bone scan
      • Highly suspected multiple bone metastases in multiple C-, T- and L-spine, sacrum, sternum, bilateral rib cages, scapulae, and bilateral multiple pelvic bones.
    • 2022-01-13 CT - lung/mediastinum/pleura
      • Findings
        • Chest:
          • Soft tissue nodule at left lobe thyroid up to 5.3cm in largest dimension with tracheal deviation to right side is found. Stationary.
          • Lobulated nodule at left lower lobe up to 7.7cm in largest dimension is found. In comparison with CT dated on 2021-12-21, the lesion is slightly enlarged.
          • Mild left pleural effusion is found.
          • Spicualted nodule at left upper lobe up to 1.0cm in largest dimension is found. In regression.
          • Several tiny nodules at both lungs. Stationary in size and numbers.
          • Enlarged lymph nodes are found at AP window and paratracheal region.
        • Visible abdomen:
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
          • No evidence of abnormal soft tissue mass at pelvic cavity.
          • No definite inguinal or pelvic sidewall LAP
      • Imp:
        • LEFT LOWER LOBE lung cancer with bilateral lung meta, extensive bone meta.
        • The primary tumor enlarged slightly. The lung meta are statinary.
        • Mediastinal lymph nodes, in slighlty enlargement.
    • 2022-01-12 MRI - brain
      • A small intra-axial enhancing nodular lesion, about 5 mm, with mild perifocal edema in left frontal lobe, indicating metastasis.
    • 2021-12-28 CXR
      • A nodular opacity projecting in the left lower lung is noted that is c/w lung cancer. Please correlate with CT.
    • 2021-12-28 Patho - lung wedge biopsy
      • Lung, LLL, CT-guide biopsy—adenocarcinoma, moderately differentiated
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
    • 2021-12-27 MRI - L-spine
      • IMP: Bony metastasis involving L2, L4, L5 and S1 vertebral bodies and bilateral iliac wings. Mild lumbar spondylosis.
    • 2021-12-21 CT - lung/mediastinum/pleura
      • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T4N2M1c, stage IVB
    • 2021-12-26 CXR
      • an oval-shaped mass over LLL, high possibly of a malignant lesion, suggest do CT study
      • Displacement of the tracheal axis to right at thoracic inlet and
      • superior mediastinum probably due to enlarged thyroid gland or
      • lymph node enlargement
  • lab data
    • PD-L1
      • 2022-01-06
        • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2021-19566
          • Tumor type: Adenocarcinoma
          • Tumor location: Lung
          • Testing assay: SP142 Assay (Ventana)
          • Testing platform: BenchMark XT
          • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
          • Control slide result: Pass,
          • Adequate tumor cells present (>=50 viable tumor cells): Yes,
        • Result:
          • Tumor cell (TC) staining assessment: TC category: TC < 1%
          • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
        • Note:
          • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
          • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • consultation
    • 2021-12-28 Orthopedics
      • Q
        • for suspected lumbar nerve compression evaluation.
        • This is a 60 year-old male, who denied having any history. He complaimts low back pain with radiation to right thigh after trauma 6 Ms ago, and limping gait, he came to our Ortho OPD follow-up, then he received the L-spine MRI on 2021/12/27. However, he was admitted for LLL lung cancer T4N2M1c stage IVB, intrathoracic goiter evaluation. So we need your help for suspected lumbar nerve compression evaluation.
      • A
        • The MRI revealed bony metastasis involving L2, L4, L5 and S1 vertebral bodies and bilateral iliac wings. No nerve compression was noticed at present.
        • Suggestion:
          • Tx of lung ca as your specialty
          • Consult radiooncologist for possible radiotherapy, if indicated.
  • chemoimmunotherapy
    • 2022-01-26 ~ undergoing - carboplatin + pemetrexed + BGB-A317 tislelizumab + BGB-A1217 ociperlimab (BGB trial)

701376921

220613

  • exam finding
    • 2022-05-26 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Metastatic adenocarcinoma, consistent with colonic primary
      • The specimen submitted consists of three strips of yellow gray soft tissue, labeled liver, measuring up to 0.4 x 0.1 x 0.1 cm. All for section.
      • The secvtions show metastastic adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
      • IHC, tumor cells reveal: CK7(-), CK20(+), and CDX2(+). The finding is consistent with colonic primary.
    • 2022-05-23 Abdominal Ultrasonography
      • Diagnosis
        • Liver tumors, S4-S5-S8 and S6, suspected hepatocellular carcinoma
        • Hepatic tumor encasing right portal vein
        • Suspect left partial hepatectomy
        • Suspect gallbladder adenomyomatosis
        • Gall stone
        • Splenomegaly
      • Suggestion
        • Please correlate with other image for hepatic tumor survey
        • Follow liver function test and AFP
  • consultation
    • 2022-05-24 Gastroenterology
      • Q
        • The 61 y/o woman has S-colon adenocaricnoma with liver and lung metastases s/p treatment in ShuangHo Hospital. She transfered to our OPD for secondary opinion. Due to liver function impairmenet, so we need your help for management.
        • O
          • GOT 33 -> 113
          • GPT 17 -> 153.
          • Abd echo was done on 20220523, report showed one huge hyperechoic lesion with hypoechoic rim, at least 13.16x12.71cm in size, was noted at S4, S5 and S8. One 4.44cm hyperechoic lesion was noted at S6, Hepatic lobe S2 and S3 was invisible.
      • A
        • 61F, a case of S-colon adenocaricnoma with liver and lung metastases s/p treatment in ShuangHo Hospital
        • S
          • Conscious clear
      • O
        • @Abdominal echo (20220523)
          • Liver tumors, S4-S5-S8 and S6, suspected hepatocellular carcinoma
          • Hepatic tumor encasing right portal vein
          • Suspect left partial hepatectomy
          • Suspect gallbladder adenomyomatosis
          • Gall stone
          • Splenomegaly
        • @LAB
          • AST: 33 (5/3) -> 99 (5/19) -> 113 (5/24)
          • ALT: 17 (5/3) -> 102 (5/19) -> 153 (5/24)
          • Bilirubin total: 0.57 (5/20)
          • Bilirubin direct: 0.18 (5/20)
          • Albumin: 3.5 (5/20)
          • Creatinine: 0.73 (5/19)
          • Alkaline phosphatase: 365 (5/19)
          • CA-199: 242.62
          • CEA: 183.415
      • A:
        • Abnormal liver function, suspect hepatic tumor related
      • P:
        • Check Anti HAV IgM, HBsAg, anti-Hbs Ab, anti-Hbc Ab, Anti HCV Ab to exclude viral hepatitis
        • Check HBeAg, Anti HBe Ab, HBV DNA
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
        • Silymarin 1#~2# TID (GOT and GPT >= 2X ULN covered by NHI)
        • If patient had symptoms of abdominal fullness, may arrange abdominal echo for ascites evaluation (consider ascites tapping if available)
  • chemoimmunotherapy
    • 2022-05-27 ~ undergoing - FOLFIRI + ramucirumab

700148929

220610

{high grade B-cell lymphoma}

[objective]

  • exam finding
    • 2022-06-09 Nasopharyngoscopy
      • Infiltrative soft tissue lesion involving R Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis.
      • Brain atrophy and leukoaraiosis.
    • 2022-06-02 Nerve Conduction Velocity (NCV), Electromyography (EMG)
      • Findings
        • MNCV: no recordable response in left peroneal nerve and left ulnar nerve; decreased CMAPs amplitude of left median, right peroneal and bilateral tibial nerves; slow motor conduction velocity of left median, left peroneal and right ulnar nerve across elbow
        • SNCV: no recordable response in left ulnar and sural nerves; delayed SNAPs onset latency and decreased amplitude of right sural nerve; slow sensory conduction velocity of right ulnar and sural nerves
        • F-wave: no recordable response of left ulnar and peroneal nerves; delayed responses of left median, right peroneal and right tibial nerves
        • H-reflex: no recordable response of left lower limb; delayed response of right lower limb
      • Conclusion
        • This NCV study suggested left lower cervical and bilateral lumbosacral radiculopathy (worse in the left), left median axonal neuropathy, right ulnar neuropathy across elbow and right ulnar neuropathy.
        • Please correlate with clinical features.
    • 2022-05-27 MRA - brain
      • Findings
        • brain atrophy with prominent sulci, fissures and dilated ventricles.
        • multiple nonspecific hyperintense patches in T2WI at bilateral periventricular white matter, leukoaraiosis is considered.
        • no abnormal bright up on DWI to suggest recent infarct.
        • increased soft tissue with abnormal enhancement involving right Meckel’s cave, with extension to superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also to foramen ovale, along the course of trigeminal nerve. This is not obviously seen in previous MRI on 20220221. Possible etiology may include: inflammatory (Tolosa-Hunt syndrome), tumor (lymphoma, less likely: trigeminal neuroma, meningioma), or sarcoidosis.
        • TOF MRA shows patent and unremarkable intracranial arteries.
      • Impression
        • Infiltrative soft tissue lesion involving right Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis.
        • Brain atrophy and leukoaraiosis.
    • 2022-04-18 Nerve Conduction Velocity (NCV), Electromyography (EMG)
      • Findings
        • The facial NCV and blink reflex study showed:
          • Facial NCV (ENOG) : 0% R/L amplitude ratio
          • Absent signal in right facial nerve.
        • Absent ipsilateral R1 by right trigeminal nerve stimulation
        • Absent ipsilateral R2 & Absent contralateral R2 by right trigeminal nerve stimulation.
      • Conclusion
        • These findings suggest right facial neuropathy.
        • Advise clinical correlation.
    • 2022-04-13 Patho - interveterbral disc
      • Bone and joint, vertebra, cervical 3-4, 4-5 ,5-6 , anterior cervical discectomy — Confirmed
      • Specimen submitted in formalin consists of multiple pieces of tan, irregular tissue with the largest piece measuring 1.5 x 1 x 0.5 cm. Representative tissue for section in one cassette after decalcification.
      • Section shows pieces of bone, degenerated ligament, and cartilage.
    • 2022-04-09 CT - brain
      • Brain atrophy.
      • No evidence of ICH, SAH or SDH.
      • No evidence of space occupying lesion in the brain parenchyma is found.
    • 2022-02-21 MRA - brain
      • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
    • 2022-01-28 CT - lung/mediastinum/pleura
      • Minimal left breast soft tissue at lower part, in regression.
      • LEFT LOWER LOBE nodule. Stable, old insult is favored.
    • 2021-12-10 MRI - c-spine
      • Degenerative spinal and disc disease.
      • Herniated disc at posterior central C3-4 level, causing moderate adjacent spinal cord compression.
      • Mild C4-5, C5-6, C6-7 spinal cord compression.
      • Bilateral C4-5, C5-6, C6-7 neuroforaminal narrowing.
    • 2021-10-12 CT - abdomen, pelvis
      • Residual nodule at left breast, residual tumor activity is considered.
      • No evidence of lymphadenopathy other than left breast.
    • 2021-06-19 CT - lung/mediastinum/pleura
      • Lymphoma s/p C/T with C/T
      • Regression of bilateral breast mass with residual mass at left breast and no visible lymphadenopathy in the current study.
    • 2021-04-07 Whole body PET scan
      • Glucose hypermetabolism in the left nasal cavity, bilateral breasts, and left lobe of the liver, probably lymphoma with involvement of multiple extralymphatic organs.
      • Glucose hypermetabolism in the right maxilla, bilateral femurs, tibiae, and left fibia, probably lymphoma with involvement of the bone marrows.
      • Increased FDG accumlation in bilateral renal pelvis and colon, probably physiological uptake of FDG.
      • Lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET/CT scan.
    • 2021-03-24 Patho - breast biospy
      • diagnosis
        • Breast, right, core biopsy — high grade B-cell lymphoma
        • Breast, left, core biopsy — high grade B-cell lymphoma
      • Section shows cores of breast tissue with diffusely infiltration of large lymphoid cells.
      • IHC: CD20(+), CD3(-), CD10(+), BCL2(+), BCL6(+), MUM1(+), cMYC(-), CD5(-), and CD30(-). The Ki-67 is about 80%.
      • The results are in favor of high grade B-cell lymphoma.
    • 2021-03-16 CT - lung/mediastinum/pleura
      • two lt lung nodules up to 6 mm, stationary, favor intrapulmonary LNs.
      • regression of Rt inguinal LNs as compare with CT study on 20201027.
      • post treatment change with calcification in anterior mediastinum.
      • bilateral breast masses.
    • 2020-10-27 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Stationary right inguinal lymph nodes.
      • Liver cysts.
    • 2020-06-29 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Some LNs (up to 6mm) at bil. inguinal regions.
    • 2020-04-30 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy - Hypocellularity and free from lymphoma involvement
      • Sections show 5-20 % cellularity. The M/E ratio is about 1/1 - 2/3. Megakaryocytes are found about 0-1/HPF. No increase of blasts is noted. There are no granulomas,foreign malignant cells, nor aggregation of atypical lymphocytes.
    • 2020-02-18 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Stationary right inguinal lymph nodes as compare with CT study on 20180802.
      • Liver cysts.
    • 2019-10-11 Surgical pathology Level IV
      • In-hospital
        • pathologic diagnosis - Breast, right, excision - Follicular lymphoma
        • Histology type: B-cell neoplasms, Follicular lymphoma
        • Follicular lymphoma - grading: 2, predominantly diffuse pattern
        • IHC: CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), CD5(-), CD21(-), CyclinD1(-), SOX11(-), and cMYC(-)
      • Dr. KungChao Chang
        • Breast, right, excision: Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)
        • Sections show breast parenchyma diffusely replaced by small to medium-sized lymphoid tumor cells with slightly irregular nuclei, inconspicuous nucleoli and focally abundant pale cytoplasm. Lymphoepithelial lesions are present, highlighted by cytokeratin immunostain.
        • Immunohistochemically, these cells are positive for CD20, CD79a, bcl-2 and MNDA (focal) but negative for CD3, CD5, CD10, cyclin D1, SOX11, IRTA1, HGAL, LMO2, CD21 and c-MYC. Bcl-6 is focally positive for some cells, probably tumor cells. The Ki-67 proliferative index is around 40%. The lymphoepithelial lesions are evident but many cells infiltrating ductal epithelium are negative for CD20 or CD79a but focally positive for MNDA. The CD10-positive cells are mainly stromal cells (fibroblasts) not lymphocytes.
    • 2019-10-28 SONO - breast
      • Post-op scar in right breast.
      • Right breast tumor, suspected fibroadenoma.
      • Left breast nodule with central hyperechoic, suspected intramammary lymph node, suggest following up.
    • 2019-10-09 Whole body PET scan
      • Glucose hypermetabolic lesion in the right breast, suggesting lymphoma involving a single extralymphatic organ in the absence of any lymph node involvement.
      • Mild glucose hypermetabolic lesions in bilateral palatine tonsils, probably chronic inflammation/infection process.
      • Mild glucose hypermetabolic lesions in the colon, probably physiological uptake of FDG.
      • Lymphoma, c-stage IE (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2018-08-02 CT - abdomen
      • S/P operation. No evidence of tumor recurrence.
      • Liver cysts (up to 1.2cm). Grade 3 fatty liver.
  • consultation
    • 2022-06-09 Radiation Oncology
      • Q
        • For evaluating and possible image-guided tissue proof
        • The 68 year old woman had Hypothyroidism under medical, Sleep disorder, Diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV, Herniated disc at posterior central C3-4 level, Autoimmune disease not eleswhere classified under rheumatology regular outpatient follow-up.
        • She complaint of neck pain and left ulnar area soreness, pain and numbness for for a month, left grips weakness and opponents weakness (left 4,5 fingers claw hand), ulnar side. And severe left ulnar area pain,soreness and numbness. Medical treatment and physical therapy was ineffective at all.
        • She visited our neurosurgery clinic, follow NCV study suggested left lower cervical radiculopathy, left median mild axonal neuropathy and left ulnar neuropathy across elbow post left cubital tunnel syndrome for neurolysis/cubital tunnel closure and anterior transposition on 2022/01/06.
        • She has left limbs weakness and numbness were noted and left drop foot. No evidence of spinal metastasis lesion from MRI in WanFang Hospital on 2022/03/21, but suspect compression fracture at T7. NCV and CMG were done, report showed mononeuritis multiplex.
        • Bone scan showed degnerative change of T8, T10 and L3 is first cinsidered on 2022/03/25. Right facial palsy, drooling, and mildly slurred speech was noted on 2022/04/07 morning on awakening. The neurologist suggested arranging a brain CT with contrast, which did not reveal any ICH, SAH, or SDH, and no space-occupying lesion in the brain parenchyma was found. The neurosurgeon suggested surgical intervention due to a previous C-spine MRI showing C4-5 herniated intervertebral disc  disease with spinal canal stenosis.
        • After discussion and the fullexplanation with the patient and her son, she decided to undergo anterior cervical discectomy for C3-4, C4-5, and C5-6 and anterior spinal fusion on 2022/04/12. She still felt right facial numbness. Arrange blink test, facial nerve stimulation and showed these findings suggest right facial neuropathy.
        • Brain MRA on 2022-05-27 revealed Infiltrative soft tissue lesion involving right Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis. Brain atrophy and leukoaraiosis.
        • Nasopharyngoscopy on 2022-06-09 showed Infiltrative soft tissue lesion involving R Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis. Brain atrophy and leukoaraiosis.
        • Under the impression of Diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV, PS:0, suspect relapse in brain .
    • 2022-04-14 Rehabilitation
      • A
        • Objective
          • imaging studies
            • 20220221 brain MRA
              • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
            • 20220409 brain CT
              • Brain atrophy.
              • No evidence of ICH, SAH or SDH.
              • No evidence of space occupying lesion in the brain parenchyma is found.
            • 20220413 c spine x ray
              • Post disectomy and disc grafting C3/4/5/6.
          • physical examination
            • 20220414 14:09 T/P/R: 36.0℃ / 89bpm / 17bpm BP:152/81mmHg
            • height: 154.0 Body weight: 56.3 BMI:23.7 Consciousness: E4V5M6
            • right facial palsy, suspected peripheral type
            • Cognition: oriented could follow orders
            • Speech: no aphasia, no dysarthira
            • Swallowing: NG (-). no dysphagia.
            • drooling on right side. right face numbness + hypoethesia
            • no choking
            • Sphincter: Foley (-), stool continence
            • MP: RUE 5 / RLE 5 / LUE 4+ / LLE 4
            • Functional status: needs min assistance in transfer
            • BADL: needs min assistance
        • Assessment
          • C3-6 herniated intervertebral disc with spinal stenosis post anterior cervical discectomy for C3-4, C4-5, and C5-6 and anterior spinal fusion on 2022/04/12
          • facial numbness, suspected peripheral facial palsy
          • pending blink reflex
        • Plan
          • Rehabilitation programs: Bedside PT rehabilitation programs
          • Goal: improve ADL ability, improve lower limb endurance
    • 2022-04-08 Neurology
      • Q
        • The 69 y/o woman has endometrium cancer and diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV. This time, she has left limbs weakness, numbness, painful sensation and unsteady gait for months on WanFang Hospital and Taipei Medical University Hospital treatment. She was brought to ED for left leg severe pain on 4/5. We need your help for management.
      • A
        • S
          • This is a 68 year old woman had aHx of
            • Diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV, s/p C/T (doxorubicin? liposomal doxorubicin? epirubicin?) and R/T (until 2022-03 for left breast)
            • Cervical cancer endometrium carcinoma s/p radical hysterectomy on 2002?08/03?
            • Hypothyroidism under medication
            • Herniated disc at posterior central C3-4 level
            • Left cubital tunnel syndrome for neurolysis/cubital tunnel closure and anterior transposition on 2022/01/06
            • Autoimmune disease not eleswhere classified under rheumatology regular OPD follow-up
          • She suffered from subacute progressive left arm numbness since 2 months ago during R/T; leg pain (burning sensation) and numbness since 1 month ago. Bilateral bottuck numbness, urine retention, constipation, annus less sensation when using toilet paper since 0.5 month ago. Right facial palsy, drooling, and mild slurred speech was noted on 2022047 morning on awakening.
        • O
          • NE
            • GCS: E4V5M6
            • VF: intact
            • pupil 3/3 t/t
            • EOM: free
            • right facial palsy, central or peripheral
            • right V1-3 hypoesthesia
            • hearing: left hearing loss (baseline)
            • mild dysarthria
            • tongue in the mid
            • motor
              • 5/P5D3
              • 5/P4D1
            • Left
              • shoulder rotation, arm abduction, elbow flexion, elbow extension, wrist extension:5
              • finger extension, finger flexion: 4
              • finger abduction, finger adduction: 3
              • thumb abduction: 4
              • left interosseous muscle atrophy
              • claw hand
            • hip flexion, hip adduction, knee extension: 4
            • hip abduction, hip extension: 3
            • foot dorsiflexion, plantarflexion inversion, eversion: 1
            • extension of toes: 2
          • sensory:
            • hypoesthesia over
              • right face, right head over
              • bilateral medial antebrachial cutaneous and left ulnar
              • bilateral buttoack and left below knee, left femoral cutaneous
          • brain MRA (20220222): Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
          • MRI: C4-5 HIVD
        • A
          • impression: mononeuropathy multiplex; Bell’s palsy
        • P
          • suggestion:
            • arrange NCV and EMG
            • arrange blink test, facial nerve stimulation test
            • arrange brain CT with contrast
            • give prednisolone 5mg 11# per day (devide to 3 times), then decrease 2# per day since day 6
    • 2021-04-22 Infectious Disease
      • Q
        • The 68 year old woman is a case of diffuse large B-cell lymphoma with multiple extralymphatic involvement over supra and infradiaphramatic region, Lugano stage IV,PS:0
        • She received C1 R-CHOP (Adriamycin shift to self paid of Lipo-dox) was administered on 2021/04/08 ~ 2021/04/09.
        • This time, she suffered dysuria for about 2 days and frequency and urgency also suffered swelling nose for about 1 day with headache. She then had fever for about 2 days.
        • At ER, hemogram showed neutropenia with ANC 362, elevated CRP. CXR was clear. Water view’s mild obliteration of the right maxillary sinus.
        • Empiric antibiotics with Cefepime was given for neutropenic fever
        • We need your expertise for antibiotics used, thanks
      • A
        • Consultation for neutropenic fever.
        • 68-year-old B-cell lymphoma female patient, who received recent chemotherapy, has neutropenic fever now.
        • White count 630 with ANC only 362 yesterday.
        • There is rhinitis symptoms, and Water’s view shows suspect right maxillary sinusitis.
        • CxR film shows clear lungs, that no urinalysis data available for interpretation.
        • Patient is receiving cefepime now, which would be appropriated for her.
        • Suggestion:
          • Check urinalysis and send urine for culture.
          • Continue Cefepime.
          • Consult ENT specialist for scope examination.
          • Check blood culture report.
  • surgical operation
    • 2022-01-06 Left cubital tunnel syndrome for neurolysis/ cubital tunnel closure and anterior transposition
      • Left ulnar area numbness/ grips muscular atropy and weakness/ claw hand.
      • Prominent left epicondyl of humerus. Severe adhesion around ulnar nerve both at para-epicondyl area, including proxiaml cutibal tunnel are/ cubital tunnel inside and distal area to FCU area.
    • 2002-08-03 radical hysterectomy at NTUH
  • chemoimmunotherapy
    • 2021-04-08 ~ 2021-09-08 - R-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone plus rituximab)
    • 2020-01-20 ~ 2020-03-11 - R-COP (cyclophosphamide, vincristine, prednisone plus rituximab)

==========

2022-06-10

  • Brain MRA (2022-05-27) revealed:
    • Infiltrative soft tissue lesion involving right Meckel’s cave, superior orbital fissure, foramen rotundum, pterygopalatine fossa, and also foramen ovale, along the course of trigeminal nerve. Suspect Tolosa-Hung syndrome, lymphoma or sarcoidosis.
    • Brain atrophy and leukoaraiosis.
  • The above described infiltrative soft tissue lesion at trigeminal nerve course is consistent with the finding of NCV (2022-04-18). DLBCL with CNS involved?
  • There is no cure or specific treatment for vanishing white matter (leukoarailsis) so far.
  • Neurological symptoms might be prioritized?
  • HR > 100, potential hypoperfusion?
  • No issue with active prescription.

2022-04-06

  • The patient underwent R-COP from 2020-01 to 2020-03 after pathologically proving follicular lymphoma in October 2019, then received R-CHOP from 2021-04 to 2021-09 after pathologically proving high grade B-cell lymphoma in March 2021.
  • There would be an increased risk of CNS involvement for patients with double-hit or triple-hit high-grade b-cell lymphomas (in this case, cMYC(-), BCL2(+), BCL6(+)), but CNS involvement was not proven by brain MRA on 2022-02-21.
  • While the standard of care is not established, the following induction regimens have been reported:
    • RCHOP (used in 2021)  - DA-EPOCH-R  - Potentially toxic regimens; performance status and comorbidities should be considered
      • R-HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine)
      • R-CODOX-M/R-IVAC (rituximab-cyclophosphamide, vincristine, doxorubicin with methotrexate/ifosfamide, etoposide, and cytarabine)
  • Laboratory results reported on 2022-03-29 indicated normal liver and kidney function, along with slightly lower CBC readings.

701009623

220606

{follicular lymphoma}

  • exam finding
    • 2022-06-02 CT - abdomen, pelvis
      • With and without contrast enhancement CT of abdomen shows:
        • Distended stomach and proximal small bowel.
        • Unremarkable chagne of the liver, spleen, pancreas, and kidneys.
        • Peritoneal stranding at low abdomen. Wall thickening and increased enhancement of terminal ileum.
        • Surgical clips and stiches over abdomen.
        • No bony destructive lesion on these images.
        • Penetrating atherosclerotic ulcer at abdominal aorta, infrarenal segment.
      • Impression
        • Gastric and proximal small bowel distension
        • Terminal ileum thickening and peritoneal stranding, due to lymphoma?
        • Suggest small bowel series to r/o obstruction if progression of bowel distension
    • 2022-06-01 Abdominal Ultrasonography
      • c/w, Ileus
      • Liver cyst, small, S7
    • 2022-05-31 Standing KUB
      • Presence of ileus.
      • S/P operation with retention of surgical clips.
      • Intact bony structure(s).
    • 2021-09-18 CT - abdomen, pelvis
      • Infrarenal AAA (2.1cm) with mural thrombus and ulceration.
  • consultation
    • 2022-06-03 General and Gastroenterological Surgery
      • Q
        • Patient admit to Cardinal Tien hospital on for operation for malignant lyphoma on 20210730, Brain MRA on 20210731 showed left MCA, PCA infarction with hemorrahge transformation. S/P HBO (Hyperbaric Oxygen Therapy) for 10 sessions, under rehab program .
        • NG(-), Foley(-)
        • Palpitations, epigastric pain with nausea, crampy sensation and shaking chills for 3 days. TOCC(-). No known allergy.
        • Abd CT:
          • Penetrating aortic ulcer (PAU) noted at infrarenal aorta, no obvious interval change.
          • Post op chage of small bowel. Some prominent LNs at mesentery, no interval change.
        • 2022/06/01 Abd SONO
          • dilated A-colon and D-colon was noted.
          • Diagnosis:
            • c/w, Ileus
            • Liver cyst, small, S7
        • 2021/09/18 CT Abd:
          • Infrarenal AAA (2.1cm) with mural thrombus and ulceration.
      • A
        • 67 y/o male small bowel lymphoma s/p segmental resection
        • bloating and abdominal pain but subside
        • PE: soft, no tenderness
        • CT: Terminal ileum thickening and peritoneal stranding, due to lymphoma?
        • P: suggest admission and further evaluation
    • 2021-09-24 Hemato-Oncology
      • Q
        • This is a 66-year-old man with history of:
          • Mesentric tumor in small bowel, s/p exploratory laparotomy with tumor excision and resection of jejunum for about 160cm on 2021-07-30, pathology report: malignant lymphoma
          • Small bowel syndrome
          • Abdominal aorta aneurysm, measuring 2.1cm
          • Pulmonary hypertension
          • Atrial fibrillation with right bundle branch block
          • Anemia, suspected chromic inflammation of GI tract
        • He had found one big mass at lower middle abdomen for one month. He went to GI department in Cardinal Tien Hospital on 2021-07-16. Abdominal echo revealed left intra-abdominal tumor, 10.2x8.8cm. Abdominal CT was arranged on 2021-07-19 and showed (1) suspected tumor, 8.9x8.8x6.3cm, in small intestine with retroperitoneal lymphadenopathy; (2) abdominal aorta aneurysm and focal dissection. Exploratory laparotomy with excision of intraabdominal tumor and resection of jejunum about 160cm was performed on 2021-07-30. Pathalogy report of operation finding revealed a follicular lymphoma, grade 2, in the mesentry, measuring 11x10x6.5cm, immunoreactive for CD20, bcl-2 and CD10 and non-reactive for CD3, CD5, CD21, CD23 and cyclin D1. After operation, acute onset of conscious disturbance with right limbs weakness was noted in 2021-07-31 early morning. Brain MRA on 2021-07-31 revealed recent infarction in the left middle cerebral artery (MCA) and posterior cerebral artery (PCA) territory with suspicious hemorrhagic transformation at the left temporal area and basal ganglia. Cardiac ultrasound on 2021-08-02 showed LVEF: 75.7% and moderate pulmonary hypertension. Whole body PET scan on 2021-08-11 showed suspicious inflammatory change in right lower lobe of lung and no evidence of abnormal FDG uptake throughout whole body region elsewhere. His consciousness was alert and E4VAM6.
        • With impression of left MCA and PCA infarction with hemorrhagic transformation on 2021/07/31 with right hemiplegia, dysphagia and aphasia, he was transferred to our PM&R ward on 2021/09/15 for further rehabilitation treatment.
        • We need your expertise for evaluation of follicular lymphoma s/p tumor excision.
        • Pathology report in Cardinal Tiem Hospital
          • Gross Description
            • The specimen submitted consisted of 2 parts. Part(A) was a segment of small intestine measuring 102 cm in length and up to 3 cm in diameter, fixed in formalin.
            • Grossly, the small intestine showed unremarkable. There was a tumor measuring 11 x 10 x 6.5 cm in the mesentery. Part(B) was a piece of soft tissue labelled mesentery lymph nodes, measuring 9 x 4 x 2 cm in size and 30 gm in weight. Representative sections were taken.
          • Microscopic description
            • Microscopically, sections of the mesentery tumor and mesentery lymph nodes show numerous variably sized, back to back neoplastic follicles. Most have absent or attenuated mantle zones. Occasional larger admixed centroblasts are seen.
            • The tumor cells are immunoreactive for CD20, bcl-2 and CD10, and non-reactive for CD3, CD5, CD21, CD23 and cyclin D1. The morphological and immunohistochemical features are compatible with follicular lymphoma, grade 2. Sections of jejunum and both cut ends show chronic inflammatory cell infiltration in the mucosa.
      • A
        • Paitent examined and Chart reviewed. A case of intestinal lymphoma is noted. I am consulted for further evaluation and management.
        • My suggestions:
          • Please complete staging work, e.g., Chest/Abd/Pelvis CT, PET-CT, bone marrow study. All is covered by National Health Insurance.
          • Please check lab: Anti-HCV, Anti-HBs Ab, Anti-HBc Ab, HBs Ag, LDH, Beta2-microglobulin.
          • Already discussed with patient and family.
          • Any problem, please let me know.
    • 2021-09-22 Cardiac Surgery
      • Q
        • After admission, follow-up abdominal CT with/without contrast for abdominal aortic aneurysm was performed on 20210918 and showed one infrarenal AAA (2.1cm) with mural thrombus and ulceration. His systolic blood pressure was around 140 mmHg and sometimes above 150mmHg recently. We need your expertise for evaluation of abdominal aortic aneurysm and target of blood pressure control. Thank you so much!
      • Q
        • Thanks for consultation.
        • CTA showed a small, if it can be diagnosed as, AAA. The diamter is 21mm. Blood pressure is well controled.
        • There is no current indication for surgical intervention. Conservative treatment with aggressive BP control is recommended. OPD f/u is recommended.

[assessment]

  • This patient was diagnosed with follicular lymphoma based on pathology results from Cardinal Tien Hospital and has undergone exploratory laparotomy with excision of intraabdominal tumor as well as resection of about 160cm of jejunum on 2021-07-30 at that hospital during the third quarter of 2021. Is it possible that the staging workup has not been completed, or that the records collected at Cardinal Tien Hospital have not been totally transferred?
  • First line therapy for follicular lymphoma grade 1 or 2 could be the following regimens:
    • Bendamustined + obinutuzumabe or rituximab
    • CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + obinutuzumabe or rituximab
    • CVP (cyclophosphamide, vincristine, prednisone) + obinutuzumabe or rituximab
    • Lenalidomide + rituximab
  • CT 2021-09-18 revealed an infrarenal abdominal aortic aneurysm (2.1cm) with mural thrombi and ulceration, while CT 2022-06-01 demonstrated a penetrating atherosclerotic ulcer at the abdominal aorta, infrarenal segment. In the TPR records since this hospital stay, SBP fluctuates between 135 and 180 mmHg, BP might not be considered well controlled, and this patient has no cardiac medicine or cardiac surgery follow up records since 2021-09, perhaps some consultation might be appropriate.
  • In this case, the patient has a history of atrial fibrillation and right bundle branch block. However, only antihypertensive medication Sevikar is prescribed now.
  • All the oral drugs in active prescription can be administered with nasogastric tube.

701391119

220601

{steroid conversion}

An approximate corticosteroid dosing conversion

  • Approximately 4mg of dexamethasone is equivalent to 4mg of betamethasone.
  • The current dose of betamethasone 4g IVD Q8H may be switched to Limeson (dexamethasone 4mg/tab) 1# PO Q8H.

701364241

220531

  • exam finding
    • 2022-03-15 Patho - pancreas biopsy
      • Labeled as “pancreatic head”, incision biopsy — adenocarcinoma.
      • Section shows 1 piece of pancreatic tissue with irreular shaped adenocarcinoma.
      • IHC stains: CK19 (+), CA-199 (equivocal), CK7 (+), CK20 (-). The pattern in conjunction with elevated levels of serum lipase and CA-19-9 is compatible with pancteatic origin.
    • 2022-03-08 MRI - pancreas
      • Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation.
    • 2022-03-07 Endoscopic Ultrasound, EUS
      • Diagnosis
        • Pancreatic head tumor with CBD invasion, highly suspected pancreatic cancer
        • Dilated biliary tree
      • Suggestion
        • Correlate with other imaging
        • Consult surgeon for indication of operation
    • 2022-03-07 Abdominal Ultrasonography
      • Diagnosis
        • Suspicious pancreatic head tumor
        • Dilated biliary tree
        • Distended GB with sludge
        • Dilated MPD
      • Suggestion
        • Correlate with other imaging
    • 2022-03-03 CT - abdomen, pelvis
      • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage): T1cN0M0, stage IA
  • consultation
    • 2022-03-23 Hemato-Oncology
      • Q
        • for chemotherapy
        • This 48 y/o male was a case of pancreatic head cancer with obstructive s/p PTCD on 3/9. Further operation was performed on 3/14. Operation finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm multiple LN enlarge at duodenal ligament and paraaorta. So Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done. After operation with well oral intake and condition become stable, we need you help for further chemotherapy for this patient.
      • A
        • This 48 y/o male was a case of pancreatic head CA wt obstructive s/p PTCD on 3/9. Op was performed on 3/14 22. Op finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm multiple LN enlarge at duodenal ligament and paraaorta. Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done.
        • Palliative or pre-neoadjuvant C/T is to be proposed.
        • Image study:
          • Pancreas MRI (3/8 22):
            • Findings
              • Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation.
              • Distention of gallbladder.
              • No ascites, nor enlarged lymph node.
              • No abnormal intensity in bilateral basal lungs.
            • IMP: Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation.
          • Abd CT (3/3 22):
            • Findings
              • Wall thickening of distal CBD with biliary tree and p-duct dilatation.
              • Distention of gallbladder.
              • Patency of portal vein.
              • No ascites, nor enlarged lymph node.
              • No abnormal density at bilateral basal lungs.
            • IMP: Wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor.
        • Dx: R/I local advanced pancreatic CA, stage, unamenable to resection.
        • Medical advice:
          • It will be possible to be cured only in the patient whose pancreatic cancer is amenable to total surgical resection ( R0 resection ). The pacnreatic tumor of this pt seeems to be unresectable.
          • Pancreatic CA divided into 2 main kinds of carcinoma, one is adenocarcinoma, another is neuroendocrine tumor. Both should be subject to complete resection for cure.
          • But the two kinds of cancer have totally different Tx pattern. For unresectable pancreatic adenocarcinoma, the first treatment of choice is palliative C/T wt FOLFIRINOX or Gemcitabine-based C/T. As for unresectable neuroendocrine tumors, the first treatment of choice may be targeted therapy wt Sutent (sunitinib).
          • If pancreatic tumor is not subjected to resection, biopsy of pancreatic tumor may be indicated for definitive Dx. Tx will be arranged according to accurate pathologic Dx.
          • If pancreatic adenocarcinoma is proved, pre-Op neoadjuvant C/T wt FOLFIRINOX or CCRT (concurrent chemoradiation therapy) over pancreatic tumor may be first priority of Tx for this pt to make pancreatic tumor shrink & may render Op feasible.
            • Post-CCRT, abd CT will be done to evaluate Op feasibility.
            • Palliative C/T regimens for local advanced pancreatic CA or metastatic Dz may be:
              • FOLFIRINOX ( self-paid ) ( preferred )
              • Gemcitabine + albumin-bound paclitaxel
              • Gemcitabine + erlotinib ( at mets dz )
              • Gemcitabine-based combination C/T
              • Gemcitabine alone
              • Capecitabine or continous infusion 5-FU.
              • TS-1 ( Phase III Clinical Study (GEST) of TS-1 in pt wt local advanced & metastatic pancreatic CA, reported at JCO 2013 March. ) ( not included at NCCN guideline recommendation )
            • Recent data showed FOLFIRINOX offered better survival benefit than Gemcitabine-based C/T.
        • If pancreatic neuroendocrine tumor (pNET) is proved, pNET (or NET) can be classified as local, regional, or advanced dz. Treatment goal should be curative where possible, with the use of pharmacological Tx as necessary.
          • If complete resection wt curative-intent can be achieved for the pNET pt without evidence of residual dz, adjuvant C/T for post-Op NET pt is not necessary. 
          • No adjuvant C/T is suggested. C/T is only considered if recurrence is proved.
        • As for the pt wt unresctable local advanced or metastatic NET, variable target therapy drugs are available:
          • mTOR inhibitor everolimus ( Afinitor, 5mg / #, 2# QD)
          • tyrosine kinase inhibitor sunitinib ( Sutent).
          • VEGF inhibitor Bevacizumab (Avastin).
    • 2022-03-23 Radiation Oncology
      • Q
        • for CCRT
        • This 48 y/o male was a case of pancreatic head cancer with obstructive s/p PTCD on 3/9. Further operation was performed on 3/14. Operation finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm multiple LN enlarge at duodenal ligament and paraaorta. So Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done. After operation with well oral intake and condition become stable, we need you help for further CCRT for this patient. Thanks for your time!!
      • A
        • Subjective:
          • History: This 48 y/o male was a case of pancreatic head cancer with obstructive jaundice s/p PTCD on 2022/3/09. BW loss of 7-8 kg in 3 months is noted. Further operation was performed on 3/14. Operation finding showed pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion, dilated CBD up to 1.8cm, multiple enlarged LAPs at duodenal ligament and paraaortic region. Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy was done. After operation, he can tolerate soft diet now.
            • Previous RT: denied.
            • Other disease: denied.
            • Family history: denied.
          • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
          • Single. Caregiver: his brother (also single). Job: nil. No economic stress.
          • Language: Mandarin. Taiwanese.
          • Religion: Nil.
        • Objective:
          • General Condition-ECOG: 1.
          • PE, 2022/3/23: No SCF LAPs. Minimal icteric sclera. 43.8 kg (51 kg before).
          • Pathology, 2022/03/15: Labeled as ‘pancreatic head’, incision biopsy — adenocarcinoma. IHC stains: CK19 (+), CA-199 (equivocal), CK7 (+), CK20 (-). The pattern in conjunction with elevated levels of serum lipase and CA-19-9 is compatible with pancreatic origin.
          • Images:
            • CT, 2022/3/03: Wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor.
            • MRI, 2022/3/08: Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation. No enlarged regional LNs. No ascites. No liver metastasis.
          • LAB, 2022/3/07: CEA 4.80; CA199, 1471.32.
        • Diagnosis:
          • Pancreatic head cancer, adenocarcinoma, with PV encasement > 270 degree and partial SMA invasion, dilated CBD up to 1.8cm (obstructive jaundice), multiple enlarged LAPs at duodenal ligament and paraaortic region, cT4N1M0, stage III, s/p PTCD on 2022/3/09, s/p Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy on 2022/3/14; ECOG =1.
        • Plan:
          • CCRT to pancreatic head tumor and LAPs for 5000cGy/25 fx is suggested for tumor control & down staging. Aggressive nutritional support is suggested due to BW loss of 7-8 kg in 3 months. CT simulation is arranged on March 29, 08:30 am. Treatment will be started on March 31 if his surgical wound heals well. Diet education and tolerable exercise is suggested.
    • 2022-03-09 Radiological Diagnosis
      • Q
        • Reason: for biliary tract drainage
        • This 48-year-old male with anxiety had regular taken medication from local psychiatric clinic. Abdomen MRI revealed Suspected a tumor (1.8cm) at pancreatic head with biliary tree and p-duct dilatation. We sincerely need your expertise for his further evaluation and arrangement of biliary tract drainage.
      • A
        • According to the clinical condition and imaging findings, PTCD is indicated.
    • 2022-03-08 General and Gastroenterological Surgery
      • Q
        • Reason: for pancreatic head tumor
        • This 48-year-old male with anxiety had regular taken medication from local psychiatric clinic. This time, he was admitted for obstructive jaundice. Abdomen CT revealed wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor. EUS revealed pancreatic head tumor with CBD invasion, highly suspected pancreatic cancer, and dilated biliary tree. MRI would be arranged on 2022/03/08 12:00. We sincerely need your expertise for his further evaluation and management.
      • A
        • S
          • According to the patient, he had weight loss of 7kg recently, postprandial diarrhea and poor appetite.
        • O
          • Lab data on 2022-03-07
            • CA199 1471.32 U/mL
            • Bilirubin total 16.82 mg/dL
            • Bilirubin direct 8.63 mg/dL
            • S-GOT/AST 137 U/L
            • S-GPT/ALT 292 U/L
            • Alkaline phosphatase 427 U/L
            • r-GT 708 U/L
          • Abdomen CT: Wall thickening of distal CBD with biliary tree and p-duct dilatation suspected tumor.
          • EUS: Pancreatic head tumor with CBD invasion
        • Impression: pancreatic head tumor, dilated biliary tree
        • Suggestions:
          • PTGBD insertion first due to hyperbilirubinemia.
          • Adequate nutrition due to weight loss.
          • Pending IgG4 and MRI report.
          • We will evaluate the need of surgery after the tests.
        • We would like to follow up this patient, feel free to contact us.
  • VS note
    • 2022-04-11
      • Local advanced pancreatic head tumor with partial SMA invasion & dilated CBD & multiple LN enlarge at duodenal ligament & paraaorta s/p Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy on 3/14 22 & s/p PTCD on 3/9 22.
      • XRT started on 4/6 22.
      • #1 pre-Op neoadjuvant CCRT with 5-FU (200mg/m2) IVF 24 hr plus R/T on 4/11 22. .
      • encourage pt to eat more food.
      • Stable vital sign. MBD today.
    • 2022-04-08
      • admitted for #1 CCRT with 5-FU (200mg/m2) on 4/8 22 due to pancreatic head CA wt obstructive s/p PTCD on 3/9 22, s/p Op on 3/14 22. Op finding showing local advanced dz wt pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion dilated CBD up to 1.8cm & multiple LN enlarge at duodenal ligament and paraaorta. Roux-en-Y hepaticojejunostomy + GJ anastomosis + cholecystectomy.
  • surgical operation
    • 2022-03-14
      • Surgery
        • Roux-en-Y hepaticojejunostomy
        • GJ anastomosis
        • cholecystectomy
      • Finding
        • pancreatic head tumor with PV encasement > 270 degree and partial SMA invasion
        • dilated CBD up to 1.8cm
        • multiple LN enlarge at duodenal ligament and paraaorta
  • radiotherapy
    • 2022-04-06 ~ 2022-05-10 - CCRT to pancreatic head tumor and LAPs for 5000cGy/25 fx
  • chemoimmunotherapy
    • 2022-05-30 ~ undergoing - FOLFIRINOX
    • 2022-04-11 ~ 2022-05-09 - 5-Fu (CCRT)

[assessment]

  • Pancreatic head cancer has been diagnosed (CT 2022-03-03) and proven to be adenocarcinoma (pathology 2022-03-15).
  • CCRT was provided to the patient starting in early April and continuing through early May 2022, following the starting of FOLFIRINOX since this hospital stay.
  • Lab data on 2022-05-30 showed grossly normal except for elevated AST/ALT, however the administration of regimen should not likely to be affected.
  • TPR remains stable during this hospitalization. No issue with active prescription.

700898650

220530

{potential drug interactions}

  • all the oral drugs in active prescription can be administered with nasogastric tube.
  • some potential drug interactions should be addressed:
    • cation exchange resin - antacid
      • Calicum polystyrene sulfonate (CPS) removes potassium by exchanging calcium ions for potassium ions in the intestine before the resin is excreted from the body.
      • The combined use of calcium carbonate (500mg PO TID) and kalimate (calcium polystyrene sulfonate, 4gm PO TID) might result in metabolic alkalosis and/or loss of efficacy of the cation exchange resin.
      • Cation exchange resins such as CPS binds magnesium and calcium ions, and may thereby prevent binding and neutralizing of bicarbonate ions in the small intestine. Additionally, this binding might attenuate the therapeutic effects of the exchange resin. Prescribing information for CPS highlights this risk of alkalosis with cation-donating antacids, but does not give specific recommendations for action.
      • To minimize this interaction, consider: a) separating the doses of calcium polystyrene sulfonate and calcium carbonate by 2 or more hours; b) administering CPS rectally; or c) choosing an alternative acid reducing agent (e.g. H2-antagonist). Monitor for metabolic alkalosis and attenuation of CPS effects if concomitant therapy cannot be avoided.
    • CNS depressants
      • The concomitant use of two or more drugs (clonazapam 0.5mg BID and fexofenadine 60mg BID) that have the potential to depress CNS function (either as a therapeutic intention or a side effect) is often clinically appropriate. However, it is important to recognize that the risk of unwanted effects may increase with such use.
      • Consider the duration of CNS depressant use and each patient’s response (particularly tolerance to CNS depressant effects) when selecting additional agents and their doses. Dose reductions of one or both CNS depressant agents may be necessary. Monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used.
      • Advise patients to avoid any unprescribed, illicit, or recreational use of other CNS depressants.
    • CNS depressant - metaclopramide
      • Metoclopramide might enhance the CNS depressant effect of CNS Depressants.
      • Metoclopramide prescribing information states that metoclopramide might impair the mental and/or physical abilities required for the performance of hazardous tasks such as operating machinery or driving a motor vehicle. Concomitant use of central nervous system (CNS) depressants or drugs associated with EPS may increase this effect (eg, alcohol, sedatives, hypnotics, opiates, anxiolytics).
      • Please monitor patients for increased CNS depressant effects (eg, somnolence, drowsiness) if metoclopramide is combined with CNS depressants.

701390387

220526

{tachycardia}

  • underlying condition
    • visually impairment
    • dementia
  • exam finding
    • 2022-05-25 CT - abdomen, pelvis
      • There is a well-defined poor enhancing lesion measuring 1.2 x 1 cm in the spleen. Please correlate with sonography and MRI.
      • There are few small ground-glass opacity on RLL of the lung that may be inflammatory process. please correlate with clinical condition and chest CT.
      • Compression fracture of T12 vertebral body. please correlate with clinical condition, old film, or MRI.
    • 2022-05-25 Chest PA
      • Ground glass opacity in right lung.
      • Normal appearance of trachea and bil. main bronchus.
      • Normal size of heart.
      • Intact bony structure(s).
    • 2022-05-25 Electrocardiography
      • Atrial fibrillation with rapid ventricular response
      • Nonspecific ST abnormality
  • lab data
    • 2022-05-25
      • CRP 20.77 mg/dL
      • WBC 11.17 *10^3/uL
      • Neutrophil 82.9 %
      • urine Bacteria 3+
      • urine Sediment-WBC >=100
      • urine Leukocyte esterase 3+
    • 2022-05-17
      • Covid-19 confirmed

[assessment]

  • Tachycardia remains evident (over 120 on 0222-05-26 morning) even under prescribed bisoprolol, with a faster breathing rate (22/min on 0222-05-25 morning) and without a high blood pressure (93/60 on 0222-05-26 04:42, this patient has HTN history). An analysis of blood gas might provide some insight into the underlying condition (sequelae of hypoventilation caused by Covid-19)?
  • Lab results on 2022-05-25 revealed CRP 20.77 mg/dL, WBC 11.17 *10^3/uL, Neutrophil 82.9 %, urine Bacteria 3+, Sediment-WBC >=100, Leukocyte esterase 3+
  • Bacterial infection is treated with Brosym (cefoperazone + sulbactam) 4g Q12H IVD since 2022-05-25. There is currently no culture outcome available.
  • No issue with current medication. Please monitor the effects of ABX.

700588193

220525

  • exam finding
    • 2022-06-01 CT - abdomen, pelvis
      • Findings:
        • There are multiple well-defined variable-sized thin wall cysts on both lung that is c/w lymphangiomyomatosis. In addition, mild right side Pleura effusion is noted.
        • There are three fatty masses on both hepatic lobes and the largest one measuring 1.8 cm in S4 that may be lipomas or angiomyolipomas.
        • Right kidney shows enlarged in size and multiple angiomyolipomas. S/P left nephrectomy? All of these findings are c/w tuberous sclerosis after correlate with prior MRI of brain.
        • S/P hysterectomy. There is ascites, multiple soft tissue lesions in the omentum and pelvis that is c/w carcinomatosis.
        • There are multiple osteoblastic change in the ribs, T-and L-spine vertebral body, sacrum, and bilateral ilium that are c/w bony metastases. In addition, There are multple enlarged nodes in para-aortic space and para-cava space that are c/w Multiple LNs metastases.
        • The urinary bladder shows small size (passive compression by the omentum tumor) and S/P suprapubic cystostomy.
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
      • Impression:
        • Carcinomatosis, bone metastases, and Multiple LNs metastases in para-aortic space and para-cava space are noted.
    • 2022-05-30 KUB
      • Fecal material store in the colon.
      • Relative Increase soft tissue density projecting at right middle abdomen and left paracolic gutter space is suspected. Please correlate with sonography and CT.
      • S/P drainage catheter insertion from right pelvis and the tip projecting at the midline lower pelvis.
      • There are several osteoblastic lesions in the sacrum and bilateral ilium that may be bony metastases?
    • 2022-05-24 EKG
      • Normal sinus rhythm
      • T wave abnormality, consider inferior ischemia
      • Prolonged QT
    • 2022-04-19 Patho - uterus with or without SO non-neoplastic/prolapse
      • Uterus Endometrial Cancer Checklist
      • Diagnosis:
        • Uterus, endometrium, total hysterectomy — Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma
        • Uterus, myometrium, total hysterectomy — Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma, by direct invasion
        • Uterus, cervix, total hysterectomy — Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma, by direct invasion
        • Ovary, right, oophorectomy — Neuroendocrine carcinoma, metastatic
        • Ovary, left, oophorectomy — Negative for malignancy
        • Fallopian tube, bilateral, salpingectomy — Negative for malignancy
        • Lymph node, left iliac, dissection — Neuroendocrine carcinoma, metastatic (2/5)
        • Lymph node, left obturator, dissection — Neuroendocrine carcinoma, metastatic (1/6)
        • Lymph node, right iliac, dissection — Negative for malignancy (0/3)
        • Lymph node, right obturator, dissection — Neuroendocrine carcinoma, metastatic (3/10)
        • Lymph node, left para-aortic, dissection — Negative for malignancy (0/1)
        • Lymph node, right para-aortic, dissection — Neuroendocrine carcinoma, metastatic (1/2)
        • Omentum, omentectomy — Neuroendocrine carcinoma, metastatic
        • Urinary bladder, partial cystectomy — The sections of urinary bladder show tumor invasion in muscular propria. The resection margin is involved by tumor.
        • AJCC 8th edition Pathology stage: pStage IVB, pT3bN2aM1; FIGO Stage: IVB
      • Microscopic Description:
        • Histologic Type: Large cell neuroendocrine carcinoma with focal small cell neuroendocrine carcinoma.
        • The immunohistochemical stains reveal CK(-), EMA(-), CD56(+), Synaptophysin(+), Chromogranin A(+), CD10(-), Cyclin D1(-), SMA(-), Desmin(-), h-Caldesmon(focal +), CD99(focal +), Melan A(-), a-inhibin(-).
        • Histologic Grade: Not available
          • FIGO Grading System applies to endometrioid carcinomas only. Serous, clear cell, transitional, small cell and large cell neuroendocrine carcinomas, undifferentiated/dedifferentiated carcinomas, and carcinosarcomas are generally considered to be high grade and it is not recommended to assign a histologic grade to these tumor types.)
        • Myometrial Invasion: present (whole thickness)
        • Uterine Serosa Involvement: Present
        • Cervical Stromal Involvement: Present
        • Other Tissue/ Organ Involvement: Right ovary, Parametrium, side not specified, Omentum
        • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
          • Ectocervical/Vaginal Cuff Margin: Free
          • Parametrial/Paracervical Margin: Not Free
        • Lymphovascular Invasion: Present
        • Regional Lymph Nodes: left iliac: 2/5; left obturator: 1/6; right iliac: 0/3; right obturator: 3/10; left para-aortic: 0/1; right para-aortic: 1/2
        • Additional Pathologic Findings: Metastatic tumors, measuring up to 0.1 x 0.1 cm, are seen in omentum.
    • 2022-04-19 Ascites
      • Diagnosis: Positive for malignancy
      • Microscopic description: Many small clusters of neoplastic cells present.
    • 2022-04-19 Frozen section
      • Preliminary diagnosis: Uterus, corpus, biopsy — malignant tumor (round blue cell tumor), wait immunohistochemical stains for final diagnosis
    • 2022-04-07 Gynecologic ultrasonography
      • Pelvis mass suspected uterine myoma degeneration (uterine pain), sized 9.57X8.34 cm
    • 2022-02-16 Peripheral Vascular Test: AV fistula
      • Access type:AV fistula
      • Site:left forearm
      • Clinical problem:maturation evaluation
      • Age of vascular access: 6 weeks
      • Result: S/P left radiocephalic AV fistula, VF at inflow radial artery (diameter 3.5mm) 313-403 ml/min, inflow anastomotic diameter 8.2mm(wide patent), juxta-anastomotic cephalic vein diameter 4.8 - 4.6 - 3.3 mm, proposed A-puncture site cephalic vein diameter 5.5mm (depth 3.1mm), continuous forearm cephalic vein, proposed elbow V-puncture site cephalic vein diameter 5.5mm (depth 3.2mm), cubital vein 6.6mm, patent cubitocephalic vein with upperarm cephalic vein diameter 6.8mm and PS 42 cm/s, discontinuity between cubital and upper arm basilic vein, continuous flow pattern over draining cephalosubclavian vein indicating no overt outflow obstruction
      • Recommendation
        • Borderline maturation of left radiocephalic AV fistula, may start to use as dialysis access sited
        • Keep on gripping exercise
      • Suggestion: Clinical follow up
    • 2021-12-23 2D transthoracic echocardiography
      • Dilated LA and LV; Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Minimal pericardiac effusion
      • Mild MR, moderate TR
      • Mild pulmonary hypertension
      • Preserved RV systolic function
    • 2021-11-25 MRA - brain
      • Findings
        • Multiple subcortical T2- and FLAIR-hyperintensities in bilateral cerebral hemispheres. suspected cortical tubers,
        • Multiple nodualr lesions along walls of lateral ventricles.
      • IMP: Tuberous sclerosis.
    • 2021-10-22 SONO Renal
      • Left kidney, absent s/p nephrectomy.
      • Right multiple renal tumors, c/w angiomyolipomas.
      • Liver tumor, ( 1.3cm) , suspected hemangioma.
  • lab data
    • 2022-06-06 Urine Culture - micturition
      • Trichosporon asahii - colony count > 100,000 CFU/cc
    • 2022-05-28 Urine Culture - catheterization
      • Staphylococcus aureus - colony count 2,000 CFU/cc
      • Antibiotic SIR MIC(mcg/mL)
        • Oxacillin S 0.5
        • Penicillin R >=0.5
        • Vancomycin S 1
        • Linezolid S 2
        • Tetracycline S <=1
        • Moxifloxacin S <=0.25
        • Trimethoprim/Sulfamethoxazo S <=10
        • Gentamicin S <=0.5
        • Ciprofloxacin S <=0.5
        • Tigecycline S <=0.12
    • 2022-04-21 VRE Culture - anal swab
      • No VRE
    • 2022-04-21 CRE Culture - anal swab
      • No CRE
  • surgical operation
    • 2022-04-18
      • Surgery
        • Diagnosis: Uterine malignancy with severe abdominal wall adhesion and bladder invansion
        • Frozen section: Uterus, corpus, biopsy — malignant tumor (round blue cell tumor), wait immunohistochemical stains for final diagnosis
        • Operation:
          • Debulking surgery
          • Adhesiolysis     - Finding
        • Uterus: Multiple papillary lesion over the uterine surface and invansive to the posterior bladder wall
        • Frozen section: Uterus, corpus, biopsy — malignant tumor (round blue cell tumor), wait immunohistochemical stains for final diagnosis
        • Bilateral adnexa: grossly normal
        • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
        • CDS: moderate bloody ascites, about 500 ml, sent for cytology
        • Severe adhesion between omentum and abdominal peritoneum, s/p adhesiolysis
        • Severe adhesion between posterior bladder wall and uterus, and malignant invasion of the uterus to bladder, s/p partial cystectomy by urologic surgeon.
        • Omentum: multiple hard, variablesized nodules (5~20 mm in diameter) infracolic omentectomy was done.
        • Liver: grossly normal & smooth
        • Appendix: grossly normal
    • 2022-04-18
      • Surgery: partial cystectomy
      • Finding: uterus tumor with bladder invasion over dome and posterior wall
    • 2022-01-13
      • Surgery
        • Long-term hemodialysis catheter implantation via right IJV
        • Intraoperative sonography
      • Finding
        • Sonographic localization of right IJV
        • C-arm fluoroscopic confirmation of catheter tip
        • Free blood withdrawal of A/V routes
    • 2021-12-23
      • Surgery
        • Left radiocephalic AV fistula creation
        • Intraoperative sonography
      • Finding
        • Moderate-sized cephalic vein with continuity to elbow, small radial artery
        • S/P left AV fistula, thrill(++)

[assessment]

  • Micturition urine culture (2022-06-06) found Trichosporon asahii colony count > 100,000 CFU/cc which is treated with teicoplanin currently.
  • Vomit OB 3+ (2022-06-06) which is being treated with pantoprazole.
  • RBC 2.84 *10^6/uL, HGB 7.5 g/dL (2022-06-06), anemia is treated with Recormon epoetin beta 5000 unit SC QW5, LPRBC is also prepared.

700526699

220524

700526699

{drug identification}

Total 14 drugs for identification.

The 10 identified items has been shown as following while the other 4 items still remain unknown:

  • Musco (ambroxol hydrochloride 30mg)
  • Viartril-S (glucosamine sulfate, polycrystalline 314mg)
  • Madopar (levodopa 100mg, benserazide 25mg)
  • MgO (magnesium oxide 250mg)
  • Merislon (betahistine 6mg)
  • Evoxac (cevimeline 30mg)
  • Clopid (clopidogrel hydrogen sulphate 97.875mg)
  • Rivotril (clonazepam 2mg)
  • Xanax (alprazolam 0.25mg)
  • Solaxin (chlorzoxazone 200mg)

These drugs will be sent back to ward by the in-hospital porter.

701240441

220523

{upper GI bleeding}

  • exam finding
    • 2022-05-22 CT - abdoemn, pelvis
      • Without contrast Abdomen CT showed unremarkable change in the organs
    • 2022-05-04 CT - abdomen, pelvis
      • . Please correlate with gastroscopy.
      • Adenomas in bilateral adrenal gland.
    • 2022-05-04 Electrocardiography
      • Normal sinus rhythm
      • Left ventricular hypertrophy with repolarization abnormality
      • Prolonged QT
    • 2022-05-04 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • No active bleeder nor coffee ground material was noted during this exam.
        • Suboptimal study due to patient’s inability to tolerate the procedure
        • Reflux esophagitis LA Classification grade B
        • Ulcerative mucosa, lower esophagus
        • Superficial gastritis
      • Suggestion:
        • Suggest repeat endoscopy for esophageal ulcer biopsy and detailed examination later
    • 2021-05-14 Abdominal Ultrasonography
      • Diagnosis
        • Negative finding
      • Suggestion
        • OPD f/u
        • Follow liver function test and AFP
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • Lab data
    • 2022-05-22
      • gastric juice Clarity Turbid
      • gastric juice Color Brown
      • gastric juice OB 3+
      • Bilirubin total 1.09mg/dL
      • WBC DC 94%
      • CRP 1.3mg/dL
      • K 2.7mmol/L
      • serum Glucose 154mg/dL
      • WBC 11.1*10^3/uL
    • 2021-05-13 ( Hepatitis B FAQ https://www.immunize.org/catg.d/p4090.pdf )
      • HBsAg Reactive 4431.01
      • Anti-HBc Reactive, 7.6
      • Anti-HBs 0
      • Anti-HCV Nonreactive, 0.05

[assessment]

  • TPR, BP were all within normal limits during this hospitalization, however, gastric juice OB 3+, slightly elevated Bilirubin total, WBC, WBC DC, CRP and serum Glucose were recorded on 2022-05-23.
  • EGD was performed on 2022-05-04 and no active bleeding was observed (in a suboptimal condition). There might be a need for a re-endoscopy. CT on 2022-05-04 showed sliding hiatus hernia. Patients with documented pathologic acid reflux who have complete or partial response to proton pump inhibitors (PPIs) are good candidates for one of the antireflux procedures. The choice of procedure depends on whether a clinically significant hiatal hernia is present. ( https://www.uptodate.com/contents/hiatus-hernia )
  • Presently, the patient is rehydrated, receiving appropriate dose of PPI, and receiving potassium gluconate for his low potassium level accordingly. All the oral drugs in active prescription can be administered with nasogasric tube. No issue with current medication.

700340565

220520

{small bowel ileus}

[assessment]

  • This patient is diagnosed with small bowel ileus and had past history of colon cancer in situ s/p OP, inguinal hernia s/p OP.
  • Small bowel obstruction can be functional or mechanical, the latter is caused by intraluminal or extraluminal mechanical compression. In developed countries, adhesion is the most common cause, followed by hernias, malignancies, and various other infectious and inflammatory disorders.
  • TPR 36.2/63/18, BP 122/52 (2022-05-20 05:35), WBC 7.37*10^3/uL, Neutrophil 93.1%, CRP 1.75mg/dL (2022-05-19)
  • Currently, no fever, tachycardia, hypotension, or altered mental state have been observed. If any of these systemic signs develop, additional laboratory testing may include: Arterial blood gas, serum lactate, blood culture, and procalcitonin.
  • The basic plain radiographic examination should include an upright chest film and upright and supine abdominal films, abdomen - standing (diaphragm) has been scheduled on 2022-05-20. CT of the abdomen could also be helpful, however, due to the low renal function, contrast might be contraindicated.
  • The patient is currently rehydrated and using laxatives to stimulate the intestinal lining. His underlying diseases (AF, HTN, CKD) are treated with corresponding self-carried drugs.
  • No issue with active prescription.

700900778

220520

  • exam finding
    • 2022-05-04 CT - abdomen, pelvis
      • Recurrent HCCs in left hepatic lobe S/P treatment show stable disease.
    • 2022-02-15 CT - abdomen, pelvis
      • Progression of HCCs and portal venous thrombosis. Progression.
    • 2022-01-24 CT - lung/mediastinum/pleura
      • no abnormality in both lungs or central airways for the cause of hemoptysis.
    • 2022-01-11 CT - liver, spleen, biliary duct, pancreas
      • Recurrent HCCs and portal venous thrombosis. Progression.
    • 2022-01-05 Abdominal Ultrasonography
      • Diagnosis
        • Cirrhosis of liver
        • Liver tumor, S3, S6, suspicious newly lesion
        • liver tumor, S4, suspicious HCC post TACE or RFA effect, suspected viable tumor
      • Suggestion
        • arrange liver dynamic CT
    • 2021-07-30 CT - abdomen
      • Recurrent HCC 7.17 x 4.61 cm in S3/4 liver is suspected.
      • The differential diagnosis include cholangiocarcioma.
      • Please correlate with tumor marker, MRI, or biopsy.
    • 2021-07-28 Abdominal Ultrasonography
      • Diagnosis
        • HCC post segment 6, 7, 8, segmental hepatectomy
        • HCC post RFA with viable HCC s/p TACE
        • Liver cirrhosis
        • Liver cyst
        • GB sludge?
        • Fatty liver, mild
        • Fatty pancreas
      • Suggestion
        • Please correlate with other image studies
        • Please arrange CT or MRI
    • 2021-06-18 MRI = liver, spleen
      • Recurrent HCC 2.8 x 2.3 cm in S2/3 liver is highly suspected.
    • 2021-03-24 CT - abdomen
      • Recurrent HCC 2.2 cm in S3 liver is highly suspected.
      • The differential diagnosis include cholangiocarcioma.
      • Please correlate with tumor marker and MRI.
    • 2021-01-11 MRI - liver, spleen
      • HCC s/p RFA without viable tumor.
    • 2020-10-21 MRI - liver, spleen
      • HCC in S4 S/P RFA shows complete response.
    • 2020-06-20 CT - abdomen
      • HCC s/p RFA and Op. No evidence of recurrent HCC in the study
      • Calcified coronary arteries is found.
    • 2020-05-05 CT - abdomen
      • Post-op at right lobe liver, developed washout nodule, 1.17cm in S8/4 region, r/o recurrent HCC.
      • Liver cyst.
      • Ascending colon diverticula.
    • 2019-11-05 CT - abdomen
      • Post-op at right lobe liver, focal low density along the surgical margin, regression.
      • Liver cyst.
      • Ascending colon diverticula.
    • 2019-05-14 CT - abdomen
      • S/P surgical resection S5/6/7 and part of S3 of the liver.
      • There is no evidence of tumor recurrence.
      • A hepatic cyst 2.1 cm in S3.
    • 2019-03-26 Surgical pathology Level V
      • pathologic diagnosis
        • Liver, S3, partial hepatectomy — Hepatocellular carcinoma, recurrent
        • Pathologic Staging (AJCC): Stage II at least (rpT2Nx(cMx))
      • microscopic examination
        • Histologic Type: Hepatocellular carcinoma
        • Histologic Grade: GIII (Poorly differentiated)
        • Cytological grade: Ⅲ
        • Tumor necrosis: Absent
        • Inflammatory cell infiltration: Moderate
        • Tumor capsule: Encapsulated with focal infiltrative border
        • Satellite nodule: Absent
        • Venous (Large Vessel) Invasion: Absent
        • Portal Vein Thrombosis: (-);Capsular vein invasion: (-)
        • Perineural Invasion: Not identified
        • Bile duct Invasion: Absent
        • Pathologic Staging (rpTNM): Stage II at least (rpT2Nx(cMx))
        • Margins
          • Parenchymal Margin: Uninvolved by invasive carcinoma, 0.5 cm from closest margin
          • Hepatic capsule: Uninvolved by invasive carcinoma
        • Additional Pathologic Findings: Focal fatty change in tumor cells and large cell dysplasia
        • Hepatitis: Hepatitis B
        • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F4 (Corresponding Metavir F3, septal fibrosis)
        • Fatty Change: Present (10%)
    • 2019-03-26 Surgical pathology Level V
      • pathologic diagnosis
        • Liver, S7, partial hepatectomy — Hepatocellular carcinoma, recurrent
        • Pathologic Staging (AJCC): Stage II at least (rpT2Nx(cMx))
      • microscopic examination
        • Histologic Type: Hepatocellular carcinoma
        • Histologic Grade: GIII (Poorly differentiated)
        • Cytological grade: Ⅲ
        • Tumor necrosis: Mild
        • Inflammatory cell infiltration: Moderate
        • Tumor capsule: Encapsulated with focal infiltrative border
        • Satellite nodule: Absent
        • Venous (Large Vessel) Invasion: Absent
        • Portal Vein Thrombosis: (-);Capsular vein invasion: (+)
        • Perineural Invasion: Not identified
        • Bile duct Invasion: Absent
        • Pathologic Staging (rpTNM): Stage II at least (rpT2Nx(cMx))
        • Margins
          • Parenchymal Margin: Uninvolved by invasive carcinoma, 0.8 cm from closest margin
          • Hepatic capsule: Uninvolved by invasive carcinoma
        • Additional Pathologic Findings: Fatty change in tumor cells and Large cell dysplasia
        • Hepatitis: Hepatitis B
        • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F4 (Corresponding Metavir F3, septal fibrosis)
        • Fatty Change: Present (10%)
    • 2019-03-22 Visceral Angiography 2 vessels
      • IMP: Bil. liver tumors suspected recurrent HCCs
    • 2019-03-08 MRI - abdomen
      • Hepatoma measuring 2.1 cm in S3 of the liver is first impressed.
      • Please correlate with clinical condition and AFP.
      • According to AJCC staging system,8th edition, CT staging of HCC:T1N0Mx
    • 2018-06-19 CT - abdomen
      • HCC, s/p segmental hepatectomy
      • No evidence of local recurrence
    • 2018-01-11 Surgical pathology Level V
      • pathologic diagnosis
        • Liver, segment 6, 7, 8, segmental hepatectomy — Hepatocellular carcinoma
        • Pathologic Staging (AJCC): Stage II (pT2Nx(cMx)
    • 2018-01-05 Visceral Angiography 2 vessels
      • Right liver tumor suspected HCC as described. Another small perfusion defect (5mm) at right hepatic lobe.
    • 2017-12-13 CT - abdomen
      • Imaging Report Form for Hepatocellular Carcinoma
        • A poor enhancing tumor (4.6cm) in S7 of liver suspected hypovascular HCC.
        • Hepatocellular carcinoma (T1N0Mx, radiology staging: stage I)
  • surgical operation
    • 2021-05-14 Radiofrequency ablation
      • Course: By sono-guided, RFA probe (COVUDIEN Cool-tip ACT 2030, 17 Fr) was inserted into the S4/5 tumor with whiteout appearance. (stop after 2 pauses)
      • Time:
        • 1st (inf part) 5:56, Power (Max100- Min60); Impedance (Max100- Min65); cool time 4:32, temp: 76C
        • 2nd (sup part) 4:32, Power (Max 90- Min60); Impedance (Max95- Min65); cool time 3:08, temp: 75C
      • Findings: HCC post RFA
    • 2020-05-29 Radiofrequency ablation
      • Course: By sono-guided, RFA probe (COVUDIEN Cool-tip ACT 2020, 17 Fr) was inserted into the S4/8 tumor with whiteout appearance. (stop after 1 pause)
      • Time: total 6:11; Power (Max80- Min60); Impedance (Max125- Min85)
      • Findings: HCC post RFA
    • 2019-03-25 Partial hepatectomy
      • Finding
        • rcurrent S3 tumor 2.0 x 1.2 x 1.2 cm
        • S7 tumor 2.5 x 2.0 x 2.0 cm
        • mild fibrosis
    • 2018-01-10 Segemental hepatectomy-three segement
      • Finding
        • 4.2 x 3.5 x 3.0 cm hepatic tumor at S6-7-8
        • small nodule at S6 suspected FNH or small HCC
  • chemoimmunotherapy
    • 2022-03-11 ~ undergoing - FOLFOX
    • 2022-01-25 - atezolizumab + bevacizumab
    • 2021-05-12 ~ 2021-08-16 - nivolumab
    • 2019-04-23 ~ 2019-07-02 - sorafenib

[assessment]

  • Under the current regimen, the recurrent HCC in the left hepatic lobe was stable on a recent CT (20202-05-04).
  • No issue with active prescription.

701000332

220518

{Vulvar Cancer}

[exam findings]

  • 2023-05-11 CXR

    • Ground glass opacities in bil. lungs.
  • 2023-05-02 CXR

    • Rt subpulmonary effusion
    • patchy bilateral areas of consolidation and ground-glass opacities as well as reticular opacities over both lungs
    • Osteoblastic metastasis in spine and ribs
  • 2023-04-26 MRA - brain

    • Clinical information: Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB
    • Findings:
      • Scattered numerous enhancing nodular lesions over whole cerebrum and cerebellum. The largest one (2.6cm) over left cerebellar lobe. Favor metastases.
      • Multifocal peritumoral edema over cerebral hemispheres and left cerebellar lobe.
      • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2023-04-07 CT - abdomen

    • Indication and History
      • Vulvar ca with lung and bone met status
      • Skull palpable mass (20201002) which grew up for 6 months -> improved after RT and chemo (20210105)
      • asks for follow up myoma due to she feels vulvar discomfort of rt vulvar tumor.
    • Findings:
      • There is IHDs dilatation and an ill-defined equivocal poor enhancing lesion 1 cm in S2 of the liver. Please correlate with MRI.
      • There are multiple osteoblastic change of the T-spine and L-spine that are c/w osteoblastic bony metastases.
      • Right side Pleura effusion
      • The gallbladder shows small contracted.
    • Impression:
      • There is IHDs dilatation and an ill-defined equivocal poor enhancing lesion 1 cm in S2 of the liver. Please correlate with MRI.
      • There are multiple osteoblastic change of the T-spine and L-spine that are c/w osteoblastic bony metastases.
  • 2023-02-24 Tc-99m MDP bone scan with SPECT

    • The Tc-99m MDP bone scan with SPECT 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the skull, both rib cages, multiple C-, T- and L-spines, sternum, left sternocalvicular junction, left S-I joint and left femoral shaft, in whole body survey.
    • IMPRESSION: In comparison with the previous study on 2021/08/09, some new bone lesions are noted and most of the previous bone lesions are more evident, indicating multiple bone metastases in progression.
  • 2023-02-22 Skull PA + Lat.

    • Several small nodular defects in the skull are suspected. please correlate with clinical condition or CT.
  • 2023-02-02 SONO - chest

    • pleural effusion, but only trivial amounts
    • right side.
  • 2023-01-31 Mammography

    • Screening digital mammography of both breasts with MLO and CC views:
      • Old mammographic study: 2021-01-15 (BIRADS 1)
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative. - annual screening.
  • 2022-12-29 CT - abdomen

    • History and indication: Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P operation.
      • Multiple bony metastases.
      • A patchy density (3.2cm) at RUL. Right pleural effusion.
      • Retroversion of uterus. A tumor (3.0cm) at uterus.
    • Impression:
      • S/P operation.
      • Multiple bony metastases.
      • A patchy density (3.2cm) at RUL. Right pleural effusion.
  • 2023-03-19, -03-10, -02-05, -01-15, 2022-10-28, -10-25, -09-27, -09-22, -08-22, -06-24 CXR

    • S/P metalic autosuture projecting at right upper lung zone.
    • Few nodular opacity projecting in right lung are suspected. Please correlate with CT.
    • Right diaphragmatic tenting is noted, which may be due to lung volume decrease of RUL.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Osteoblastic change of right upper ribs are suspected that are compatible with bony metastases after correlate with CT.
  • 2022-09-06 CT - abdomen

    • Clinical vulva cancer.
    • Sclerotic densities in the bones, suspected bone metastasis.
    • Uterine tumor, suspected uterine myoma.
    • Regression of left lobe liver hypodense lesions.
    • Bilateral pleural effusion, more prominent at right side.
    • Consolidations in right lower lung.
    • Fibrotic infiltrates in RUL.
  • 2022-08-16 Gynecologic ultrasonography

    • LT adnexae: free
    • Uterine myoma
  • 2022-07-05 Laryngoscopy

    • Findings
      • bi nasopharynx smooth, hypopharynx smooth mucosa, normal vocal function, right vocal cord anterior part edema,
    • Conclusion
      • chronic corditis
      • no evidence of vocal palsy
  • 2022-06-16 Neurosonology

    • Normal vessel wall in bilateral extracranial carotid arteries.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor left temporal windows for transcranial insonation.
  • 2022-06-16 Brainstem Auditory Evoked Potentials, BAEP

    • Findings
      • Normal absolute and inter-peak interval latencies of brainstem auditory evoked potentials from both ear.
    • Conclusion
      • Normal BAEP.
  • 2022-06-15 MRI - brain

    • mild dilated intraventricular and extraventricular CSF spaces
    • punctate white matter gliosis in the bilateral frontal, parietal and parietal lobes; old lacunar infarction in the pons.
    • unremarkable change in the skull base
    • no abnormal brain parenchymal enhancement.
  • 2022-06-02 CT - lung/mediastinum/pleura

    • Finding
      • Chest
        • Septal infiltration and peribronchovascular bundle infiltration is found at residual lung fields. In comparison with CT dated on 2022-02-23, the lesion is stationary.
        • Bilateral hilar and mediastinal lymphadenopathy is found.
        • Patent airway is found.
        • S/p port-A placement with its tip at Superior vena cava.
        • Right pleural effusion is found.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • Increased intestinal gas is found.
        • Low density lesion at left lobe liver is found, causing left IHD focal dilatation. Stable.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp: Compatible with bilateral lung mets, liver and bone meta with stationary tumor extension.
  • 2022-05-24 Gynecologic ultrasonography

    • Uterine myoma
  • 2022-04-08 Chest XR

    • S/P port-A implantation.
    • S/P metalic autosuture projecting at right upper lung zone.
    • Few nodular opacity projecting in right lung are suspected. Please correlate with CT.
    • Fibrosis at right upper lung is noted. Please correlate with clinical history and CT.
    • Right diaphragmatic tenting and right hilum elevation is noted, which may be due to lung volume decrease of RUL.
    • Osteoblastic change of right upper ribs are suspected that are compatible with bony metastases after correlate with CT.
  • 2022-03-14 Laryngoscopy

    • subacute corditis, improved with vocal cord fibrotic change
    • no evidence of vocal palsy
  • 2022-03-11 Chest XR

    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-03-01 Gynecologic ultrasonography

    • Uterine myoma
  • 2022-02-23 CT - lung/mediastinum/pleura

    • Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB
    • comparison made with previous CT dated on 2021/11/06
      • Lungs
        • stationary of metastatic nodules and septal and peribronchovascular interstial thickening in both lungs (most severe at RUL and LLL)
        • stationary of metastatic lymphadenopathy in Rt precarinal space and both hila
      • Vessels:
        • Aorta: normal caliber, minimal atherosclerotic change of aortic arch.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: bilateral pleural effusions and scattered Rt upper pleural thickening.
      • Chest wall: small LNs in left supraclavicular fossa
      • Visible abdominal contents:
        • several poorly enhanced areas in peripheral S6 and left lobe of liver, stable.
        • normal appearance of gallbladder.
        • unremarkable of the spleen, adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no onvious ascites.
      • Visualized bones: blastic metastatic change in multiple vertebrae, sternum, and ribs, stable.
    • Impression:
      • stationary metastatic lung, liver, bony lesions, and LAPs in mediastinum and hila, as compared with CT dated on 2021/11/06
  • 2022-01-17 Laryngoscopy

    • acute corditis, maybe related to previous Foster use
    • no evidence of vocal palsy
  • 2022-01-03 Laryngoscopy

    • acute corditis, maybe related to previous Foster use or chemotherapy
    • no evidence of vocal palsy
  • 2021-11-06 CT - lung/mediastinum/pleura

    • Compatible with vulva cancer with left lower lobe lung meta. In progression.
    • Mediastinal lymphadenopathy, stable
    • Liver and adrenal meta. In progression.
    • Bone meta. stationary.
  • 2021-10-26 Bronchodilator test

    • FVC: 50%, FEV1: 44%, FEV1/FVC: 72%.
    • negative bronchodilator test.
  • 2021-08-09 Tc-99m MDP whole body bone scan

    • The Tc-99m MDP bone scan with SPECT 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the left parietal region of the skull, both rib cages, multiple C-, T- and L-spine, sternum, left sternocalvicular junction, upper portion of left S-I joint and left femoral shaft, in whole body survey.
    • Impression: In comparison with the previous study on 2021/04/09, all lesions are old and show less evident, indicating multiple bone metastases with partial response to current therapy.
  • 2021-07-19 CT - lung/mediastinum/pleura

    • regression metastatic lung lesions and LAPs in mediastinum and hila, but progression of bony metastasis compared with Ct on 2021/04/15.
  • 2021-04-09 Patho

    • Skin, left post-auricular, excision - poorly differentiated carcinoma, metastatic.
    • IHC: ER positive (strong, >95%), PR: positive (moderate, 90%), CK20(-), P40(-), CEA(+).
  • 2021-02-25 Patho

    • scalp metastatic cancer nodule
    • IHC: CD56(-), GATA-3(+), mamoglobin(focal +). The pattern is the same as those of S2019-15699/S2019-15746.
  • 2021-01-29 MRA - Brain

    • A newly developed left cerebellar metastasis.
    • Marked regression of the left parietal skull and scalp metastasis.
    • Brain atrophy and leukoaraiosis.
  • 2021-01-13 CT

    • metastasis 1.2cm in S2 liver is suspected.
    • there are three soft tissue nodules in left diaphragm.
  • 2020-10-28 Tc-99m MDP whole body bone scan

    • Suspected Ca with multiple bone mets in the left parietal region of the skull, both rib cages, some T- and L-spine, and left femoral shaft, M/3.
    • Suspected benign lesions in C-spine, maxilla, mandible, bilateral sternocalvicular nctions, shoulders, elbows, knees, and right foot.
  • 2020-10-21 CT

    • newly developed T3 vertebral metastasis.
  • 2020-07-06 MRI - Brain

    • Left parietal scalp, skull metastasis with intracranial extension.
  • 2020-07-03 CT

    • post operative change at right upper lobe with pleural thickening, in progression.
    • recurrent pleural meta is favored.
  • 2019-09-18 Patho

    • Lung, right, upper, middle, lower lobe, wedge resection - poorly differentiated carcinoma, metastatic.
    • Histologic Type: carcinoma, The morphology is consistent with S2017-19644.
    • IHC: GATA3(+), Mammaglobin A(focal +), ER(+, 100%), PR(+, 20%), HER-2/Neu(Ab): Negative (1+), PAX8(-), p63(-), Uroplakin II(-), CK5/6(-), Chromogranin A(-), CD56(-), and TTF-1(-). The Ki-67 is about 40%. The results are most compatible with breast origin.
  • 2019-09-05 CT: multiple lung nodules, favor metastatic lesions.

  • 2019-06-03 CT: uterine myoma is suspected.

  • 2017-12-13 CT: a 3.0cm tumor at uterus.

  • 2017-11-28 Patho

    • Right vulva, excision biopsy - Carcinoma, margin positive.
    • IHC: GATA-3(+), GCDFP-15(-), CK7(+), CK20(-), p40(-), p16(focal +), HMB-45(-).

[consultation]

  • 2023-05-15 Family Medicine
    • Q
      • The 64 y/o woman has vulva cancer with mulitple lung and brain mets /p chemotherapy and under RT. Due to con’s disturbance with V/S unstable, so we need your help for hospice care. Thanks!
    • A
      • 64-year-old female, DM, HTN, dyslipidemia
        • Vulva cancer with mulitple lung and brain metastasis s/p chemotherapy, under radiotherapy
        • This time suffer from alteration of consciousness
        • Consciousness E3V3M5, ECOG 4
        • Advance Care Planning Document” or “Advance Directive.” (+)
        • We will arrange hospice combine care and follow up her condition
        • Consider hospice ward if families agreed with palliative treatment
        • Thanks for your consultation.
  • 2023-04-26 Radiation Oncology
    • A
      • A: Carcinoma of the vulva, right aspect, s/p excision, with positive margin, s/p simple vulvectomy, stage pT1b(cN0M0), s/p radiotherapy, with lung metastastases, s/p operation (thoracoscopic segmentectomy of lung, thorecoscopic excision of mediastinal tumor, thoracoscopic wedge or partial resection of the Lung), and s/p chemotherapy, with left parietal scalp and skull metastasis, s/p chemotherapy and radiotherapy, and status during chemotherapy, with multiple brain metastases.
      • P: Radiotherapy is indicated for this patient with the following indicators: multiple brain metastases.
        • Goal: palliation
        • Treatment target and volume: metastatic brain lesions
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 2400cGy/12 fractions of the metastatic brain lesions
        • The patient already received radiotherapy before. The treatment modality and the possible effects of re-irradiation were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2023-05-03.
  • 2023-04-24 Neurology
    • Q
      • She was admitted for chemotherapy on 4/24,but according to family, she began to repetitively chew with her mouth and slurred speech was noted for one week, suspect parkinson’s disease.
      • We need your expertise for further management, thanks
    • A
      • repeated praying in the morning 1 week ago, vertigo in these days
      • NE: aware, fluent speech, chewing of mouth, suspect right visual hemineglect, left side weakness and dysmetria
        • with equivocal left Babinski signs
      • Impression:
        • suspect recurrent brain metastasis and encephalopathy
      • Suggest:
        • brain MRA with contrast might be arranged
        • I would like to follow up this patient. Thank you for your consultation.
  • 2022-06-13 Neurology
    • Q
      • The 63 y/o woman has Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB. She has dizziness progress in recently days. Anemia, but no SOB or tachycardia condition, so we need your help for dizziness management. Thanks!
    • A
      • This is a 63 y/o woman with history of vulvar carcinoma with multiple lung metastases and cerebellar metastasis, s/p excision, s/p simple vulvectomy, rcT1b(cN0)M1, stage IVB. She complained positional dizziness and vertigo sensation while lying down for one week. Anemia was also noted. Piracetam and betahistin were prescibed since 20220610. She felt better after taking betahistin. She denied focal weakness, unsteady gait, falling, nausea, vomiting, headache, tinnitus, and hearing impairment.
      • NE
        • GCS: E4V5M6
          -VF: no hemianopia -light reflex: 3/3 +/+ -EOM: free and full -no facial palsy
          -Muscle power:
          -RUE/LUE: 5/5 -RLE/LLE: 5/5 -Babinki: plantar/plantar -Sensory: intact and symmetric -FNF: np dysmetria -HKS: no dysmetria -Gait: narrow base, steady -Tandem gait: no falling.
      • Exam
        • 2021/01/29 brain MRI: left cerebellar metastasis
        • 2022/06/12 Hb:8.9
      • Assessment
        • central vertigo, suspected brain metastasis, suspected VBI (Vertebrobasilar insufficiency)
      • Suggestion
        • arrange brain MRI with/without contrast to r/o new brain metastasis.
        • arrange carotid-duplex, BAEP.
        • Keep current Nilasen 1 tab BID.
  • 2022-01-25 Oral and Maxillofacial Surgery
    • Q
      • The 63 y/o woman has Multiple lung metastases from carcinoma of the vulva, s/p excision, s/p simple vulvectomy ,rcT1b(cN0)M1,stage IVB. She received chemotherapy on 1/25-1/27.
      • Due to complicated extraction of tooth 24, we need your help for removed stitches on 1/27.
    • A
      • We had removed stitches of oral cavity were done.
      • Education home care.
  • 2021-04-29 Neurosurgery
    • Q
      • For suspect radiculopathy due to bone metastasis of spine
      • A case of vulvar carcinoma with lung, liver and bone metastases in progression
      • This 62 y/o woman with DM, cerebral vascular calcification, left breast benign neoplam s/p excision, right vulvar carcinoma s/p vulvectomy on 2018/01/15. She also received chemtherapy, immunotherapy Opdivo. However, the disease still progressed. CT in March showing mediastinal LN, lung, liver and bone metastases in progression. This time, She was admitted for salvage treatment.
      • Right shoulder and arm pain was complained. Bone scan on 2021/04/09 revealed increased activity in the left parietal region of the skull, both rib cages, multiple C-, T- and L-spine, sternum, left sternocalvicular junction, upper portion of left S-I joint and left femoral shaft in whole body survey.
      • Due to bone mets of spine noted, we need your expertise for whether there’s rediculopathy due to bone meta of spine and further management suggestion.
    • A
      • We areconsulted due to bone metastasis (spine).
      • Suggest conservative treatment (medication) first.
      • Surgical intervention is not recommended at present.
      • C-spine MRI with may be arranged if the sign of radiculomyelopathy worsening.
  • 2020-11-20 Oral and Maxillofacial Surgery
    • A
      • Due to we need do the XGEVA, so we need your help for management.
    • Q
      • This is a 62 female suffer from tooth pain over lower left jaw for a while.
      • S: She complain tooth pain when drinking water.
      • O: 45: cervical abrasion without pulp exposed, EPT(+), Cold test(+), lingering pain(?)(patient can not distingulish), percussion(-), palpation(-) probing WNL.
      • A: tooth 45 pulpitis
      • P:
        • Take dental Pano film and physical examination for evaluation.
        • Explain the finding and treatment plan to the patient.
        • Suggest desensitization toothpast first
        • OPD for 45 OD or endodontic treatment if irriversable pulpitis occur. Do not need to extraction at this moment.

[surgical operation]

  • 2021-04-08 Excision of left post-auricular tumor
  • 2021-02-25 Excision of scalp tumor
  • 2018-01-15 Vulvectomy
  • 2017-11-28 Excision of right upper vulvar major

[chemoimmunotherapy]

  • 2023-03-20 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-22 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-26 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

  • 2022-11-25 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

  • 2022-11-04 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

  • 2022-10-13 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

  • 2022-09-27 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr

  • 2022-09-05 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3850mg 46hr

  • 2022-08-22 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • 2022-07-29 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • 2022-07-13 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • 2022-06-28 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

  • 2022-06-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr

  • 2022-05-30 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr

  • 2022-05-06 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr

  • XXXX

  • 2021-12-27 ~ undergoing - Onivyde (irinotecan liposome) + FL

  • 2021-04-28 ~ 2021-12-03 - FOLFOX + Bevacizumab

  • 2020-11-24 ~ 2021-04-06 - Nivolumab

  • 2020-10-02 -

  • 2020-07-23 ~ 2020-09-25 - Cisplatin + Vinorelbine, Vinorelbine, take turns alternately

  • 2019-10 ~ 2019-12 - Cisplatin + Paclitaxel

==========

2022-09-28

[assessment]

  • The blood sugar level was 76 mg/dL on 2022-09-28 06:05; Glimet (glimepiride plus metformin) might be held temperately. Please follow up on the new serum glucose readings.

2022-06-13

[assessment]

  • CT 2022-06-02 showed the bilaterial lung mets was stationary.

2022-05-30

[assessment]

  • Compared to the previous CT images, which were taken on 2021-11-06, the last CT images on 2022-02-23 revealed metastatic lung, liver, bones, and a LAP in the mediastinum and hilar region were stationary. It is possible that a new CT scan will be necessary.
  • Since 2020-04-10, almost every CXR has shown fibrosis in the right upper lung. If lung fibrosis becomes a concern, nintedanib or pirfenidone are likely to provide some relief.
  • The blood sugar recorded was 142 mg/dL (2022-05-30 06:54, HbA1c 6.8% 2022-05-24) while on Galvus Met (vildagliptin + metformin) and Glimet (glimepiride + metformin). In the event of a spike observed, some insulin may be beneficial.

2022-03-17

[assessment]

  • In contrast to previous CT images on 2021-11-06, CT images updated on 2022-02-23 showed stationary metastatic lung, liver, bones, and LAPs in the mediastinum and hilar region.
  • Lab tests reported on 2022-03-16 indicated no abnormalities in liver and kidney function, but low WBC, RBC, and HGB levels were observed, which should be monitored as usual in patients undergoing chemotherapy
  • According to the blood sugar level as of 2022-03-17, the level is slightly low, which should be noted and monitored if anti-DM drugs need to be adjusted.

701385762

220517

  • initial presentation
    • 2022-05-12 Emergency
      • abd pain for 1 week, poor appetitie for 3 days
      • lower leg edema 3+
      • bloody stool passage once months ago
      • denied abd Op hx
      • BW: 65 kg -> 40+ kg in half a year
      • Single. This patient lives in the north, and her family lives in the south
  • exam finding
    • 2022-05-16 Gynecologic ultrasonography
      • Asites(+)
      • IMP: Pelvis mass:145x88mm with blood flow.
    • 2022-05-12 Chest PA erect view
      • Faint aveolar opacity over left lower lobe is found.
      • Another opacity over right lower lobe is found.
      • Patent airway is found.
      • Normal heart size.
    • 2022-05-12 CT - abdomen, pelvis
      • Abdominal CT with and without enhancement revealed:
        • Solid soft tissue necrotic mass at pelvis probably originates from left ovary is found up to 10.59cm in largest dimension. Ovarian cancer is favored.
        • Massive ascites with free air at pelvic cavity, suspected peritonitis.
        • Several low density heterogeneous tumors are found at both lobes of liver up to 8.6cm at S5/6 of liver.
        • Bilateral mild pleural effusion is found.
        • Thrombus formation at INFERIOR VENA CAVA is found. Please exclude the possibility of pulmonary embolism if there is dyspnea.
      • IMp:
        • Huge pelvic mass with liver necrotic tumors, ovarian cancer with liver meta is most likely.
        • Massive ascites with air pockets, suspected peritonitis.
        • INFERIOR VENA CAVA thrombus formation.
  • lab data
    • Blood K (potassium)
      • 2022-05-17 2.4 mmol/L
    • D-dimer
      • 2022-05-17 2420.90 ng/mL(FEU)
    • Gastric Juice OB
      • 2022-05-16 3+
    • Blood WBC
      • 2022-05-12 23.11 *10^3/uL
      • 2022-05-14 27.18 *10^3/uL
    • WBC DC (differential count) Neutrophil
      • 2022-05-17 98%
      • 2022-05-14 99%
    • Blood CRP
      • 2022-05-12 14.09 mg/dL
    • Blood Albumin
      • 2022-05-17 2.3 g/dL
      • 2022-05-12 1.9 g/dL
    • Blood Total Protein
      • 2022-05-17 4.8 g/dL
    • Urine Bacteria
      • 2022-05-12 3+
    • Blood CEA
      • 2022-05-14 54.77 ng/mL
    • Blood CA125
      • 2022-05-14 100.58 U/mL
    • Blood CA199
      • 2022-05-14 100.58 U/mL
  • consultation
    • 2022-05-16 Gynecology and Obstetrics
      • Suggestion and plan:
        • Compatible with CT report, pelvic mass 15x8 cm, with ascites.
        • Please check d-dimer, aFP, LDH.
        • Please arrange panendoscopy and colonscopy.
        • Ascites cell block
        • If these data are available, contact us
    • 2022-05-12 Colorectal Surgery
      • Assessment
        • huge heterogeneous tumor in the pelvis with marked ascites, diffuse carcinomatosis and liver metastases, colon origin or GYN cancer is considered
      • Plan
        • We had well explained her terminal cancer disease to the patient and her friend (family?) and they can understand.
        • Due to diffuse carcinomatosis and liver metastases, her disease is unresectable and incurable, and has been in very terminal stage, we suggested palliative treatment and hospice consultation.
        • We would like to follow this patient.

[assessment]

  • The presence of a large heterogeneous tumor in the pelvis, with ascites, diffuse carcinomatosis, and liver metastases from the colon or gynecological origin could be considered (2022-05-12 CT abd, 2022-05-16 SONO Gyn). Further investigation is needed, working up now.
  • Heart rate roughly maintained at more than 100 beats per minute (from TPR records), this tendency of tachycardia might be caused by inferior vena cava thrombosis (2022-05-12 CT) decreased preload, decreased cardiac output, and leads to increased frequency.
  • The active prescription rehydrates, adjusts electrolytes, and supplements albumin with no problems.
  • Urine bacteria 3+ (2022-05-12) is treated with Brosym (cefoperazone, sulbactam) since 2022-05-13, body temperature never reached 37 degrees these days.
  • No issue with current medication.

700350760

220513

  • diagnosis
    • gastrointestinal hemorrhage
    • hypo-osmolality and hyponatremia
    • hypovolemic shock
    • acute posthemorrhagic anemia
  • exam finding
    • 2022-05-10 Chest PA erect view
      • Presence of ileus.
      • Ground glass opacity in right lung.
      • Normal appearance of trachea and bil. main bronchus.
      • Atherosclerosis of the aorta.
    • 2022-05-09 Abdominal Ultrasonography
      • Suspected bladder wall thickening
      • Prostate hypertrophy
      • Stool impaction
      • Ascites, small
      • Pleural effusion, bilateral
      • Pericardial effusion
      • Parenchymal renal disease and renal cysts, both
    • 2022-05-06 Esophagogastroduodenoscopy (EGD)
      • Incomplete study due to much coffee ground material and looping
      • Reflux esophagitis LA Classification grade B
      • Superficial gastritis
      • Deformed antrum
      • Suggestion: 2nd look endoscopy is warranted only if ACITVE BLEEDING sign or PERSISTED Tarry stool.

[assessment]

Harnalidge (tamsulosin) 0.4mg PO QDAC should be replaced with Urief (silodosin) 8mg PO QD as a preferred alternative.

700376437

220513

  • exam finding
    • 2022-05-09 CT - abdomen, pelvis
      • Multiple HCCs with peritoneal seeding, LNs/ lung/ bony metastases and massive ascites.
    • 2022-05-09 KUB
      • Diffuse hepatomegaly with poor defination of both kidneys, spleen, and psoas shadows, and inferiorly displaced bowel loops
      • Abdominal ascites
    • 2022-05-09 Chest PA erect view
      • Numerous nodules of variable sizes throughout both lungs due to metastases.
      • Normal heart size
      • Costophrenic angles are preserved
      • Diffuse hepatomegaly
    • 2022-04-25 Paracentesis
      • Procedure
        • Ascites tapping
      • Course
        • After echo localization, local anesthesia was performed at RLQ and 2200ml serosanguinous ascites was drained out with 18Fr catheter.
      • Findings
        • Massive clear ascites was noted.
      • Complication
        • No immediate complication
    • 2022-04-23 Chest PA erect view
      • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • 2022-04-18 KUB
      • Ascites and hepatomegaly is noted.
    • 2022-04-14 CT - abdomen, pelvis
      • Progression of bil. HCCs with PVT, peritoenal seeding, LNs, spine, lung metastases. Massive ascites.
    • 2022-04-14 Paracentesis
      • Procedure
        • Ascites tapping
      • Course
        • After echo localization, local anesthesia was performed at RLQ and 2200ml serosanguinous ascites was drained out with 18Fr catheter.
      • Findings
        • Massive clear ascites was noted.
      • Complication
        • No immediate complication
    • 2022-03-22 Paracentesis
      • Procedure
        • Ascites tapping
      • Course
        • 18G needle was inserted at RLQ under echo guided insertion.
      • Findings
        • 2000ml clear yellowish ascites was drained. 75ml was sent to lab exam
      • Complication
        • No immediate complication
    • 2022-03-18 CT - CTA, chest
      • D-dimer 3280 suspected pulmonary embolism
      • Imp:
        • Huge HCC at right lobe liver with previous rupture, PV thrombosis and left lobe tumor, lung mets.
        • No evidence of pulmonary embolism nor aortic dissection is found.
        • Massive ascites and bilateral mild pleural effusion.
    • 2022-03-17 Chest PA/AP view
      • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2022-03-16 Paracentesis
      • Ascites tapping 3000mL
    • 2022-02-15 CT - liver, spleen, biliary duct, pancreas
      • Impression:
        • Huge HCCs with portal veins invasion, newly developed left lobe HCCs.
        • Peritoneal carcinomatosis, T-spine metastasis, diffuse lung metastasis. Disease in progression.
    • 2022-03-14 KUB
      • Ascites is noted.
    • 2022-01-21 Tc-99m MDP whole body bone scan
      • Mildly increased activity in the lower T-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
    • 2021-11-20 CT - abdomen, pelvis
      • Huge hepatic tumors (up to 29cm) at S4-5-6-7-8 with right portal vein thrombosis and hemoperitoneum. No evidence of active bleeding.
      • Multiple lung metastases.
    • 2021-10-12 Visceral Angiography 2 vessels
      • DSA of celiac trunk and SMA via right common femoral artery puncture revealed:
        • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
        • Thrombosis of right portal vein.
        • Hypervascular tumors at S4 and right hepatic lobe c/w HCCs. No evidence of active bleeding.
        • No procedure-related complication during the whole procedure. Remain the arterial sheath (4 Fr) at right inguinal region. Thanks for your further care.
      • IMP: Bil. HCCs with right portal vein thrombosis as described.
    • 2021-10-12 CT - CTA, abdomen
      • History and indication: abdominal pain
      • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
      • CTA of abdomen revealed:
        • Huge hepatic tumors (up to 26cm) at S4-5-6-7-8 with right portal vein thrombosis and rupture causing hemoperitoneum.
        • Multiple lung metastases.
        • Normal appearance of spleen, pancreas, adrenals and kidneys.
        • Normal appearance of gallbladder.
        • Intact bony structures.
        • No enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
      • Imaging Report Form for Hepatocellular Carcinoma
        • Impression (Imaging stage): T4N0M1, stage IVB
    • 2021-10-12 Abdominal Ultrasonography
      • Hepatic tumor, multiple, probably metastatic tumor
      • Ascites
  • consultation
    • 2022-05-10 Family Medicine
      • Q
        • For Hospice care.
        • A 46-year old man patient is a case of liver cell carcinoma with lung and bone metastasis. admitted to ICU for AKI with GI bleeding.
        • Nasal cannula support.
        • Current problem: Con’s clear, the family and the patient prefer palliative care. We need your specialist to evaluate and Hospice. Thanks.
      • A
        • After discussion, I decided to arrange hospice combine care for him first. Our nurse will contact the family.
        • Indication: liver cell carcinoma with lung and bone metastases
        • Plan: hospice combined care
    • 2022-05-09 Nephrology
      • Geneal weakness, dsypnea, poor appetite, coffee ground vomitus and tarry stool passage note for about 1 wk
      • Vital signs: BP 115/65mmHg, PR 101/min, RR 20/min, SPO2 98%
      • Lab data
        • BUN: 22 -> 130
        • Cre: 1.03 -> 9.17
        • Na: 129, K: 6.2
        • T bil: 9.74, GOT: 121, GPT: 88, Albumin: 3.4
        • PH: 7.245, PCO2: 34.2, HCO3: 14.5, BE: -12.3
        • CXR: numerous nodules of variable sizes throughout both lungs due to metastases
        • EKG: sinus tachycardia
      • Impression:
        • Acute kidney injury stage 3 suspect prerenal or postrenal
        • HCC with lung metastases, supsect short survival period
      • Suggestion:
        • On foley and record urine output
          • First medical treatment for hyperkalemia and metabolic acidosis
          • Follow up ABG, electrolyte (ABG: Artery Blood Gas)
          • Check Abdomen CT to rule out other obstructive uropathy
          • If progressive refractory metabolic acidosis, hyperkalemia, fluid overload and anuria, we will arrange RRT if patient and family agree (RRT: Rapid Response Team)
          • Patient refuse HD and prefer medical treatment first when we explain the condtion to him in ER
          • Consider hospice care if patinet prefer DNR
    • 2022-03-18 Cardiology
      • Q
        • The 46 y/o man has hepatocellular carcinoma with right portal vein thrombosis and lung metastasis, cT4N0M1, stage IVB, BCLC: C, child score: A, under Kyetruda and Nexavar treatment. Due to SOB and elevated d-dimer level, the CTA was done and report showed huge HCC at right lobe liver with previous rupture, PV thrombosis and left lobe tumor, lung mets. We need your help for thrombosis assessment. Thanks!
      • A
        • We were consutled for HCC associated PVT.
        • CT finding on 20220318 showed
          • Huge HCC at right lobe liver with previous rupture, PV thrombosis and left lobe tumor, lung meta.
          • No evidence of pulmonary embolism nor aortic dissection is found.
          • Massive ascites and bilateral mild pleural effusion.
        • Suggestion
          • Liver cirrhosis with portal vein thrombosis easy occured in late‐stage liver cirrhosis; it is very poor prognosis. anticoagulation with warfarin maybe some benefit and also increasing fatal risks, including bleeding, tumor bleeding. Maybe you could discuss with GI man.
          • There is no specific endovascular intervention for malignancy and cirrhosis related portal vein thrombosis.
    • 2021-11-23 General Gastroenterological Surgery
      • Q
        • For management of HCC
        • This 46-year-old man has past medical history of chronic hepatitis B, Liver cirrhosis; HCC with lung metastasis, rupture, s/p emergent TAE, portal vein thrombosis. Stage T4N0M1: IVb, BCLC stage C; undergoing R/T. F/U in GS and R/T OPD; undergoing 1st immunotherapy with Nivolumab 100mg (By GS surgeon).
        • This time, due to he suffered from shortness of breath, poor intake and tarry stool for 2 days. He was brought to our ER for help. Under the impression of: 1) GI bleeding, favor variceal or PUD bleeding both considered related; 2) HCC with lung metastasis. he was admitted to our ward for further treatment.
        • After admission, NPO with IV fluid supplement and high dose PPI pump was used. Glyperssin 1amp Iv Q6H was used to correct favor EV, GV bleeding. Explained this condition to himself (including do EGD for further survey) but he refused. There was no tarry/bloody stool nor vomiting coffee ground found after medical treatment. Try clear liquid diet since 20211122 by himself request. Last time follow up hemogram on 20211123 revealed Hb:8.1 g/dL. Now, due to he request consulted GS Dr. Chen visited. We need your further survey and management of HCC.
      • A
        • huge HCC over right lobe with lung metastasis
        • liver cirrhosis, child A
        • under R/T and nivolumab Tx now
        • we will take over this case
    • 2021-10-21 Gastroenterology
      • Q
        • This 46 years old male a case of rupture HCC with lung metastasis cT4N0M1, stage IVB s/p angiography (no active bleeding) on 20211012. Hepatitis survey revealed HBsAg: reactive, Anti-HBc: reactive, Anti-HBs: nonreactive, Anti-HCV(-), HBV DNA is pending. We need your expertise for HBV treatment.
      • A
        • 46M
        • PHx: denied
        • PI: rupture HCC with lung metastasis cT4N0M1, stage IVB s/p angiography (no active bleeding)
        • Plan
          • For immunotherapy, may prescribe self-paid baraclude 0.5mg QD (prescribe 1mg to peel half can save money)
          • NHI does not cover
          • GI OPD follow up
    • 2021-10-20 Radiation Oncology
      • Assessment: HCC, stage cT4N0M1, with lung meatstases.
      • Plan: Radiotherapy is indicated for this patient with the following indicators: Huge hepatic tumors (up to 26cm) with mild dyspnea
      • Goal: palliation
      • Treatment target and volume: hepatic tumor
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/20 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and would like to receive radiotherapy. The treatment planning of radiotherapy will be started at 2PM, 2021-10-25.
    • 2021-10-12 General Gastroenterological Surgery
      • Q
        • After feeling something rupure on his RUQ on 20211008, he started severe diffused abdominal, diarrhea, urinary frequency/dysurea, nausea sensation, easily dyspnea and dizziness.
        • Left leg numbness aggressive in recently.
        • BW loss 10 kg in 1/2 yr.
        • 20211006 AFP: 22898, HBV-Ag: (+)
        • 20211012 Abdomen echo:
          • Hepatic tumor, multiple, probably metastatic tumor
          • Ascites
        • Past history: Left leg trauma s/p surgery
        • Allergy: nil
        • TOCC: (-)
      • A
        • emergent TAE
        • admit to ICU

[assessment]

  • This patient has advanced HCC with lung mets, AKI, indicating poor prognosis. Paracentesis has been performed several times in recent months for ascites tapping. Hospice combined care has been arranged this week.
  • Low RBC and HGB readings (2.66 * 10^6/uL, 8.4 g/dL 2022-05-13) might be caused by GI bleeding, 2022-05-11 vein blood gas PO2 64mmHg, O2 saturation 89%. Ventilation becomes more important when oxygenation is low.
  • Hyperphosphatemia and hypocalcemia might result from renal dysfunction. 2022-05-13 blood ammonia 100 umol/L, BUN 120 mg/dL. If the patient does not wish to undergo hemodialysis, lactulose or lactitol might alleviate hyperammonemia.

701264039

220513

{mediastinum small cell carcinoma with pericardial effusion with SVC syndrome, stage IV}

[objective]

  • exam finding
    • 2022-03-11 CT - lung/mediastinum/pleura
      • suspected IPF (idiopathic pulmonary fibrosis)
      • Extensive mediasitinal lymphadenopathy, in regression with mild SUPERIOR VENA CAVA compression.
    • 2022-01-19 Chest PA/AP view
      • S/P median sternotomy with metalic wires fixation.
      • Patchy opacity projecting at right suprahilum and Diffuse miliary lesions on both lung are notd.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette
    • 2021-12-08 Patho - soft tissue biopsy
      • diagnosis
        • Mediastinum, biopsy - Small cell carcinoma
        • Thymus, thymectomy - Involution
        • Lymph node, regional, thymectomy - Negative for malignancy (0/2)
      • IHC: CD56(+), chromogranin(+), CK(+), LCA(-) and TTF-1(-).
    • 2021-12-07 Cell block
      • suspect small cell carcinoma
      • smears and cell block show small clusters of malignant tumor cells with inconspicuous nuclei, high N/C ratio, scanty cytoplasm, pleomorphism, hyperchromasia and nuclear molding.
        • reference: S2021-18038
    • 2021-12-03 CT - chest
      • T4N3M0, stage IIIC
        • T4: Tumor > 7cm or tumor of any size invading one or more of the following: diaphragm , mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different lobe of the ipsilateral lung.
        • N3: Contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).
        • M0: No distal metastasis (in this study)
  • surgical operation
    • 2021-12-07
      • surgery
        • partial pericardiectomy
        • thymectomy
        • mediatinal tumor biopsy
      • finding
        • Some masses at mediastinum with mass effect to SVC.
        • Pericardial effusion.
        • Bil. lung fibrosis.
  • chemotherapy
    • 2021-12-10 ~ undergoing: etoposide + cisplatin
    • 2021-04-07 ~ undergoing: nintedanib (for interstitial lung diseases)

==========

2022-05-13

  • No updated image since last hospitalization. Last CT on 2022-03-11 showed suspected IPF and mediastinal lymphadenopathy, the latter was in regression under recent regimen [etoposide + cispaltin].
  • Patients with extensive-stage small cell lung cancer are generally treated with chemotherapy and immunotherapy. Extensive-stage disease is not considered to be curable, and the goals of treatment are to relieve symptoms caused by the cancer and to prolong life.
  • People who respond well to chemotherapy may be given radiation therapy to the brain to prevent the development of brain metastases, and may also receive radiation therapy to the chest. Radiation therapy may also be used to treat other areas of the body to relieve symptoms caused by the spread of cancer. As this patient also has pulmonary fibrosis, treatment outcomes for patients with lung cancer and IPF were generally poor, and exacerbations resulting from treatment were frequent. (source: https://www.nature.com/articles/s41598-021-87747-1 )
  • In order to determine whether radiotherapy is feasible, there is a published article that states that patients with lung cancer associated with ILD have a poor prognosis. They are at high risk of severe and even fatal radiation pneumonitis. Careful patient selection is necessary, appropriate high-risk consenting and strict lung dose-volume constraints should be used, if these patients are to be treated with thoracic radiotherapy (reference: Is Thoracic Radiotherapy an Absolute Contraindication for Treatment of Lung Cancer Patients With Interstitial Lung Disease? A Systematic Review https://pubmed.ncbi.nlm.nih.gov/35168842/ )
  • 2022-05-12 vein blood gas PO2 23mmHg, O2 saturation 36%. When oxygenation is low, ventilation becomes more important. Under 100% O2 mask, the patient’s respiratory rate remains at approximately 18 ~ 22 per minute so far during this hospital stay.
  • NT-proBNP was found to be 521 ng/mL and CKMB was 7.0 ng/mL on 2022-05-11, suggesting possible myocardial injury. Could myocardial injury be the result of low oxygenation? The blood pressure (105/62 2022-05-13 04:28) currently under antihypertensive agent (amlodipine + valsartan) was “too normal” in readings with somewhat tachycarida (> 100 pulse/min) even when CRP was 4.39 mg/dL and WBC was 13.45 103/uL. The coronary perfusion should be monitored if it is always adequate.

2022-04-01

  • This patient presented with stage IV mediastinum small cell carcinoma, recent CT scan taken on 2022-03-11 showed extensive mediastinal lymphadenopathy, in regression with mild superior vena cava compression.
  • The goals of management for malignant SVC syndrome are to alleviate symptoms and treat the underlying disease. Treatment of the underlying cause depends on the type of cancer, the extent of disease, and the overall prognosis, which is closely linked to histology and whether or not prior therapy has been administered.
  • The patient has been receiving [nintedanib] since April 2021 then [etoposide + cispaltin] have been added since mid December 2021 s/p [partial pericardiectomy and thymectomy] early December 2021. According to the aforementioned CT examination results, the current treatment should still be effective.
  • Laboratory data indicate slight low serum magnesium levels for months since the end of 2021. This might be related to the administration of cisplatin. MgO tablets are currently being administered.

2022-03-11

  • It is common for patients with SCLC to have extensive stage of the disease. Unlike limited-stage cancers, extensive-stage cancers are not recommended to be treated with high radiation doses intended to cure the disease.
  • T4N3Mo, stage IIIC, was shown in the CT images of 2021-12-03, which is classified as a limited but not extensive stage using VA system in NCCN guidelines.
  • Using individual patient data from four randomized studies, meta-analysis has been conducted to compare cisplatin-based versus carboplatin-based regimens for patients with SCLC. Among the 663 patients included in this meta-analysis, 32% had a limited-stage disease and 68% had an extensive-stage disease. As a result, no significant difference was observed in response rate (67% vs. 66%), progression-free survival (PFS) (5.5 vs. 5.3 months), or overall survival (9.6 vs. 9.4 months) in patients treated with cisplatin-containing versus carboplatin-containing regimens, indicating equivalent efficacy in patients with SCLC.
  • Trilaciclib or G-CSF may be used as prophylactic options to reduce the incidence of chemotherapy-induced myelosuppression in patients receiving platinum/etoposide (might plus immunocheckpoint inhibitor if applicable) containing regimens or topotecan containing regimens.
  • Electrolyte disorders including hyponatremia, hypokalemia and hypomagnesemia might be associated with administration of cisplatin or carboplatin. Lab readings for Na, K, and Mg in the past few months have been low. Monitoring is needed.

700936145

220511

  • exam finding
    • 2022-05-09 KUB
      • Degeneration of bony structures.
      • Stool retention in bowl.
    • 2022-05-09 Chest PA erect view: Essential negative findings
    • 2022-05-04 CT - abdomen, pelvis: Unremarkable
    • 2022-05-04 KUB: Unremarkable
    • 2022-05-04 Chest PA erect view
      • Lung markings: focal increased density in the left middle lung field. Please f/u.
  • 2022-05-10 admission
    • cheif complaint
      • This 59 year-old male has the histories of 1) DM; 2) Hypertension; 3) Hyperlipidemia; 4) HBV.
      • This time, he suffered from palpitations, epigastric pain with nausea, crampy sensation and shaking chills for 3 days. The epigastralgia was persistent but no radiation. There was no fever, no cold sweating, diarrhea or constipation accompanied. He denied alcohol drinking recently, hematemesis or tarry stool passage and no tea-color urine found. He visited our ER for help. At ER, vital sign was BT:36.6C, BP:141/88mmHg, PR:103/min, RR:18/min, SpO2 96% under room air. Con’s: E4V5M6. PE revealed tenderness over epigastric area. Lab data revealed leukocytosis (25.73 *10^3/uL) with elevation of CRP level (8.44 mg/dL), impaired liver function (ALT/AST 263/222 IU/L) and hyperbilirubinemia (total Bil 4.53 mg/dl), prominent elevation of lipase level (870 U/L).
      • Under the impression of acute pancreatitis, he was admitted to our GI ward for further evaluation and management.
    • past history
      • DM
      • HTN
      • Hyperlipidemia
      • HBV
      • Denied other admission or operation history. 
    • family history
      • Family history is unremarkable.
      • There is no family history of cancer, hypertension, mental diseases or asthma.
      • No members of the family with diabetes.

[assessment]

  • Vital signs (TPR 36.8/70/16, BP 122/71, SpO2 95%, 2022-05-11 04:45) were stable during this hosptial stay so far.
  • Active prescription
    • Fluid replacement with 0.9% NaCl, lactated ringers (Ca 2.19 mmol/L 2022-05-11), nako no.5
    • Pain management with Tramadol
    • Symptom mitigation with serine protease inhibitor gabexate mesilate
    • Use silymarin as a hepatoprotectant
    • Brosym (cefoperazone + sulbactam) for possible infection.
    • High blood sugar level treated with human insulin
    • Diovan (valsartan) for underlying hypertension
  • Up to 20 percent of patients with acute pancreatitis develop an extrapancreatic infection (eg, bloodstream infections, pneumonia, and urinary tract infections). When an infection is suspected, antibiotics should be started while the source of the infection is being determined. However, if cultures are negative and no source of infection is identified, antibiotics should be discontinued. Culture order might be considered.
  • No issue with current medication

701050716

220511

  • exam finding
    • 2022-05-10 Chest PA/AP view
      • Blunted right costophrenic angle.
      • S/P Port-A infusion catheter insertion.
      • Atherosclerosis of the aorta.
    • 2022-04-25 PD-L1 Immunostaining
      • Tumor Cell (TC) staining assessment < 1%
    • 2022-04-08 KUB
      • S/P double J catheter insertion in place, left side.
      • Lumbar spondylosis.
      • Calcification in the pelvic cavity, could be due to phlebolith.
    • 2022-04-07 Renal ultrasound
      • Impression
        • Mild hydronephrosis, left kidney.
        • Mass lesion in the urinary bladder, suspected Bladder tumor, suspected bladder blood clot.
        • Suspected dislocation of left double-J catheter
      • Suggestion
        • Follow up KUB to detect the location of double-J catheter.
        • Cystscopic study is recommended.
    • 2022-04-06 ECG
      • Atrial fibrillation
      • Left axis deviation
      • Incomplete right bundle branch block
      • Poor wave progression V1~3
      • Possible Inferior infarct, age undetermined
      • Abnormal ECG
    • 2022-04-05 Chest PA erect view
      • S/P port-A implantation.
      • Atherosclerotic change of aortic arch
      • Tortuosity of thoracic aorta
      • Enlargement of cardiac silhouette.
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
      • Patchy consolidation of the right lower lung is suspected.
      • please correlate with clinical condition or CT.
    • 2022-03-03 KUB
      • S/P double J catheter insertion in place, left side.
      • Lumbar spondylosis.
      • Calcification in the pelvic cavity, could be due to phlebolith.
    • 2022-03-02 Patho - urinary bladder TUR
      • Pathologic diagnosis
        • Urianry bladder, “tumor”, TURBT — Invasive urothelial carcinoma, high-grade
      • Microscopic examination
        • Histologic type: Urothelial carcinoma, invasive
        • Histologic grade: High-grade
        • Tumor configuration: Nodular
        • Muscularis propria: Present
        • Lymphovascular invasion: Not identified
        • Microscopic tumor extension: Tumor invades muscularis propria
    • 2022-03-01 ECG
      • Sinus rhythm with Premature ventricular complexes
      • Inferior infarct, age undetermined
    • 2022-02-23 CT - lung/mediastinum/pleura
      • atherosclerosis of aorta with ascending aorta dilatation 4.5 cm in caliber.
      • moderate 2V-CSD. small pericardial effusion.
      • subsegmental atelectasis of RML.
      • substantial subpleural paraseptal emphysema at anterior LUL.
    • 2022-02-11 CT - abdomen, pelvis
      • UCC of the urinary bladder with left UVJ invasion causing obstructive uropathy.
    • 2022-02-10 Chest PA erect view
      • Port-A catheter inserted into SVC via left subclavian vein.
      • Blunting of right costophrenic angle due to pleural effusion
      • moderate enlarged cardiac silhoutte may be due to dilated cardiac chambers (LAD and LVD) and prominent cardiophrenic angle mediastinal fat pad
      • patch at right inferior paracardiac lung region, could be atelectasis of RML
    • 2021-12-30 CXR
      • S/P Port-A infusion catheter insertion.
      • Right pleural effusion. Ground glass opacity in RLL.
      • Atherosclerosis of the aorta.
      • Suggest clinical correlation.
    • 2021-11-20 CT - abdomen, pelvis (ShuangHo Hospital)
      • Urinary bladder cancer s/p treatment, still thickening of urinary bladder wall.
      • Lt hydroureteronephrosis.
      • Loculated fluid or urinary diverticulum at left pelvic region.
      • Consolidation over right basal lung with pleural effusion. Ubsegmental atelectasis over left basal lung.
    • 2021-09-27 Pathology (SH2119345, ShuangHo Hospital)
      • Urinary bladder, TUR-BT, urothelial carcinoma, nested variant.
      • Urinary bladder, labeled as “tumor base, TUR-BT” urothelial carcinoma.
      • Some muscle tissue invaded by the carcinoma is seen.
    • 2021-09-17 CT - abdomen (ShuangHo Hospital)
      • Enhancing soft tissue (5.8cm) at left posterior urinary bladder wall with hyperdense collection in the urinary bladder.
      • Left severe hydroureteronephrosis noted, suspect UVJ invasion. C/W urinary bladder cancer causing hematuria, suspect UVJ invasion. (UVJ: ureterovesical junction)
    • 2020-08-13 Exercise Electrocardiogram
      • Resting ECG: Normal sinus rhythm
      • Exercise: Nonspecific ST change
      • Conclusion
        • negative for myocardial ischemia
        • isolated VPCs at the exam
  • consultation
    • 2022-01-04 Thoracic Medicine
      • Q
        • Cigarette smoking for more than 50 years, quitted this September after diagnosis of bladder cancer, hypertension for 20 years and DM, hyperlipidemia, gastric ulcer. Due to pneumonia and he was discharged from MICU at ShuangHo Hospital in 2021-12. He mentioned productive cough, mild chest discomfort, easy shortness of breath while fast walking, walking stairs about 2-3 floors, lower limbs edema after discharge. In our service, he also has cough with pneumonia under antibiotic treatment. The lung function test showed small airway obstruction, resulting in low lung volume with significant response to bronchodilator, so we need your help for COPD?
      • A
        • Assessment
          • bladder cancer on CCRT by ShuangHo
          • PN with parapneumonic pleural effuison, acute respiratory failure, 110-12, tx at ShuangHo - with residual RML abscess and lung consoidation, residual pleural effuison
          • COPD, under sipolto by ShuangHo, ex-smoking, PFT showed both restriction and airway obstruction.
        • Suggestion:
          • Due to the CXR had no interval change since 2021-12-04, and pt did not have toxic sign clinically, only f/u was suggested
          • Add spiolto 2 puff QD for him.
          • Check TB sputum X 3 days
          • OPD F/U
  • surgical operation
    • 2022-03-02
      • Surgery
        • TURBT and left URS exam        
      • Finding
        • Diffuse thickening of urinary bladder wall at left lateral wall    
        • U/O was identified after TURBT; incomplete URS exam, no tumor, no stone was found until the level of upper ureter
    • 2021-09 TURBT, transurethral resectionof bladder tumor, ShuangHo Hospital
  • radiotherapy
    • 2021-10-12 ~ 2021-11-19 - 4500cGy/25 fractions of the whole bladder and 5040cGy/28 fractions of the bladder tumor.
  • chemoimmunotherapy
    • 2021-10-12 ~ 2021-11-19 - 5Fu + cisplatin, 3 times, CCRT, ShuangHo Hospital.

[assessment]

  • CXR (2022-05-10) revealed blunted right costophrenic angle and atherosclerosis of the aorta. Lab data (2022-05-10) showed generally normal results.
  • Respiratory symptoms are well-managed with self-carried drugs in active prescription.
  • PD-L1 tumor cell < 1% (2022-04-25), the effectiveness of pembrolizumab, nivolumab or avelumab might not be very great.
  • The genetic alteration of FGFR3/FGFR2 has not been confirmed, so it is unclear whether erdafitinib should be considered.
  • Regimen for treatment of the cacner could be
    • Gemcitabine and cisplatin followed by avelumab maintenance therapy, or
    • DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin) with growth factor support followed by avelumab maintenance therapy
  • No issue with current medication.

700140236

220509

[objective]

  • exam finding
    • 2022-05-07 Chest PA/AP view
      • Increased infiltration over RLL. May be active infection.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-05-07 MRA - brain
      • Patchy area of acute ischemic infarct over right anterior MCA territory. (MCA: Middle Cerebral Artery)
      • Also focal acute ischemic cortical infarcts over both superior frontal and parietal lobes and right occipital lobe.
      • Multifocal areas of old infarction over left PICA territory, left PCA territory and left cerebral hemispheres. (PICA: Posterior Inferior Cerebellar Artery; PCA: Posterior Cerebral Artery)
      • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
    • 2022-05-07 CT - brain
      • Focal area of faint hypodense change over right frontal lobe, may be recent ischemia. Multifocal areas of old ischemic infarcts over left PICA territory, left PCA territory and left cerebral hemispheres. One old lacuna infarct within right putamen. There is no intracranial hemorrhage seen.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
      • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
  • consultation
    • 2022-05-07 Neurology
      • This 79 y/o woman has a history of arrhythmia, old stroke with left limbs ataxia, lung adenocarcinoma s/p and suspicious lung abscess. She had had anticoagulant before but discontinued medication since last year. She was able to walk slowly and could live alone with ADLs independently. Today her son visited her at around 11am and found her slow speech and left limbs weakness. Therefore she was sent to our ER for help. According to the patient’s and family’s statement, the patient could talk normally on the phone last night and this morning she had breakfast between 8:30-9:00. For acute ischemic stroke, I was consulted.
      • NE
        • E4V5M6 slowly speech,
        • left hemineglect and hemianopia
        • right gaze deviation
        • left facial palsy
      • MP
        • upper >4/3
        • lower >4/3
      • sensation: intact
      • FNF: left dysmetria
      • brain CT: right MCA territory equivocal hypodense lesion, left cerebellar/occipital region old insult
      • impression: right MCA large infarct
      • suggestion:
        • do MRA/MRI stat and consider EVT accordingly (EVT: endovascular thrombectomy)
        • give aspirin 1# stat and IV Ns 40ml/hr
        • neurology ward admission
      • Brain MRI: right frontal infarct, patent large vessel
  • progress note
    • Problem: Acute infarcts in right frontal lobe, onset on 2022/05/07
    • Assessment: Dysarthria and left side weakness
    • Plan:
      • Keep closely monitor neurological signs and vital signs Q4H ~ Q6H
      • Keep adequate IV hydration with normal saline at 40ml/hr
      • Keep antiplatelets agents: Bokey 1# QD
      • H2 block or PPI after acute stroke stage
      • Stroke etiology survey: Arrange sugar, lipid, carotid duplex, ABI, cardiosonography, 24 holter if need
      • Explained to the patient and family about current condition and managment

[assessment]

  • Acute ischemic infarction in the right anterior MCA territory occurred on 2022-05-07 in the morning. GCS remained at E4V4M5 during this hospitalization so far. Lab data 2022-05-07 showed slightly elevated CRP 1.22 mg/dL, WBC 12.22 *10^3/uL, Neutrophil 88%, and CXR revealed increased infiltration over RLL, body temperature was no more than 37 degree Celsius.
  • No issue with blood sugar (115 mg/dL 2022-05-08 17:43, 129 mg/dL 2022-05-09 06:17).
  • A tendency toward tachycardia (111 pulse/min 2022-05-09 04:14) might indicate hypoperfusion in the infarcted area, however, blood pressure has been kept at a very “normal” level (131/72), there might be no need of administration of beta-blocker yet at this moment.

700580399

220509

[objective]

  • exam finding
    • 2022-05-02 MRI - brain
      • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
      • Imp: Abnormal signal intensity change (with water movement restriction) on caudate nucleus, posterior corpus callosum and possible bil. medial temporal lobes (uncus), cause?
    • 2022-04-29 Electroencephalography
      • Abnormal, marked continuous diffuse cortical dysfunction in bilateral hemsiphere
    • 2022-04-28 CT - brain
      • IMP: No evidence of intracranial hemorrhage.
  • consultation
    • 2022-05-05 Mental Health
      • Q
        • This is a 47 y/o female who had HX of depression for 10+ years ago, but poor medication compliance. (Medication as Estazolam, Trazodone and Alprazolam).
        • This time, she was admmited to our MICU for the impression of 1) encephalopathy favor hypoglycemia and suicide (BZD over dose).
        • Now, consciou became E4M5V1 (with eyes contect but can not obey) and irritable, we need your expirence for evaluation!
      • A
        • Psychiatric impression:
          • suspected delirium, mixed level of activity
          • suspected neurocognitive disorder due to another medical condition (unknown time duration of concious loss when sending to hospital)
        • Clinical course:
          • This is a 47 y/o female, with history of depression, taking Estazolam, Trazodone, Alprazolam.
          • She was sent to ER on 20220428, coma, found in bedroom by family. Lab data showed hypoglycemia, BZD positive in urine, not sure if she has drug overdose. She was then admitted to ICU, intubation in 20220429, extubation 20220505 morning. We are consulted for conscious disturbance and irritable.
          • MSE: Confusional in conscious, mental muddy and perplexity features. kempt, lying on the bed, not agitated, with O2 mask and NG tube. She has fair eye-contact, intermittently smiling, quit, seems like unable to understand instruction well. She couldn’t express, most of the time she stares when being asked question, only occasionally making sounds with hoarsening voice, incomprehensible. According to caregiver, she becomes more agitated and irritable at night, and physical restraint was applied last night. Unable to follow order to eye-tracing, or moving specific limb. Unable to answer her name, age.
        • Suggestion:
          • Please stablize medical condition as your expertise and monitor mental condition.
          • Psychiatric medication is not essential under current condition. Psychiatric evalutaion will be provided if the patient become more clear.

[assessment]

  • During this hospitalization, the blood sugar levels were greater than 100 mg/dL, except for the first measurement of 86 mg/dL on the TPR panel. Hyperglycemia might be reclassified as an inactive item on the problem list.
  • GCS E4V2-3M5 2022-05-09 08:27, alprazolam 0.5mg was administrated. If the patient’s mental status becomes clear, then a mental health consultation may be considered.
  • There are drugs prescribed to treat underlying conditions, as well as supportive care provided. No issue with current medication.

700522990

220506

[objective]

  • exam finding
    • 2022-05-05 Abdominal Ultrasonography
      • Periampullary tumor, causing CBD/MPD obstruction, close to or invaded to IVC, with PTCD in situ
      • C/W cholangitis change, lower CBD
      • C/W A-colon cancer, with luminal stricture but no evidence of obstruction
      • Pancreatic cystic lesions, head-body, suspected IPMN
      • GB polyps
      • Hepatic cyst, left lobe
      • Renal cyst, LK
    • 2022-05-04 CT - abdomen, pelvis
      • suspected colon cancer
      • suspected pancreatic head or ampulla vater cancer.
    • 2022-05-04 CT - brain
      • no acute intracranial hemorrhage
  • lab data
    • Bilirubin total
      • 2022-05-06 9.97 mg/dL
      • 2022-05-04 16.82
    • S-GPT/ALT
      • 2022-05-06 55 U/L
      • 2022-05-04 67
    • S-GOT/AST
      • 2022-05-04 113 U/L
    • RBC
      • 2022-05-06 3.61 *10^6/uL
      • 2022-05-04 3.92
    • HGB
      • 2022-05-06 7.9 g/dL
      • 2022-05-04 8.7
  • surgical operation
    • 2022-05-05 PTCD drainage

[assessment]

  • 2022-05-06 04:45 vital signs TPR 35.9/68/16, BP 132/64 were relatively stable, low energy consumption. This patient has been diagnosed with primary hypertension, her tissue perfusion might be less than usual. No antihypertensive agents are prescribed currently.
  • The abdominal ultrasonography performed on 2022-05-05 showed periampullary tumors causing CBD/MPD obstruction and A-colon tumor with luminal stricture, which might need further evaluation to determine if they should/could be resected.
  • After PTCD drainage on 2022-05-05, bilirubin total decreased to 9 mg/dL (2022-05-06) from 16 mg/dL (2022-05-04).
  • RBC decreased to 3.61 (2022-05-06) from 3.92 (2022-05-04), HGB decreased to 7.9 (2022-05-06) from 8.7 (2022-05-04). ABO, Rh typing, antibody screening have been performed on 2022-05-06.
  • There are no records of drug allergies in the database. There are no issues with the current medication.

701254197

220506

[objective]

  • exam finding
    • 2022-03-04 SONO chest
      • right side minimal amount of pleural effusion, 600cc serosangious fluid was drained out for symptom relief.
    • 2022-03-03 Chest PA erect view
      • Atherosclerotic change of aortic arch
      • Pleura effusion of right costal-phrenic angle
      • Few nodular opacity projecting in the both lung are suspected. Please correlate with CT.
    • 2022-02-25 CT - abdomen, pelvis
      • FINDINGS:
        • Prior CT identified an ill-defined mild heterogeneous enhancing mass in left hepatic lobe is noted again, increasing in size that is c/w cholangiocarcinoma S/P C/T with progressive disease.
        • Prior CT identified several metastatic lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space and para-cava space are noted again, mild increasing in size that is c/w progressive disease.
        • Prior CT identified several small metastasis on both lung are noted again, mild increasing in size.
        • Prior CT identified mild right side Pleura effusion is noted again, increasing in volume.
        • Ascites in the abdomen and pelvis is noted.
        • Prior CT identified tumor seeding in bilateral ovary (more severe on right side) are noted again, stable in size.
        • Segmental sigmoid colon shows enhancement and thickening that may be tumor seeding in left ovary with sigmoid invasion? Please correlate with colonoscopy.
        • S/P colostomy at left transverse colon.
        • S/P R/T device implantation in the vagina is suspected? please correlate with clinical history.
        • Compression fracture of T12 vertebral body.
      • IMP:
        • Cholangiocarcinoma at Lt lobe liver shows progressive disease.
    • 2021-11-26 Patho - liver biopsy needle/wedge
      • pathologic diagnosis
        • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with cholangiocarcinoma
        • IHC shows: CK7(+), CK20(few tumor cells+), and Hepatocyte(-).
    • 2021-11-24 CT - abdomen, pelvis
      • Cholangiocarcinoma at left lobe liver shows mild increasing size.
    • 2021-08-11 CT - abdomen, pelvis
      • Cholangiocarcinoma at left lobe liver shows mild increasing size.
      • Lobulated metastatic tumor in right ovary shows mild increasing in size. please correlate with clinical condition.
    • 2021-06-06 CT - abdomen, pelvis
      • Lobulated metastatic tumor in right ovary shows mild increasing in size. please correlate with clinical condition.
      • Segmental sigmoid colon shows enhancement and thickening that may be normal variation or tumor? Please correlate with colonoscopy.
    • 2021-04-13 CT - abdomen, pelvis
      • Stationary of left lobe cholangiocarcinoma and lymph nodes metastasis.
      • Stationary peritoneal carcinomatosis.
      • Suspected right ovarian metastasis, stationary.
      • Colon diverticulosis.
      • Multiple lung nodules, suspected lung metastasis.
    • 2021-03-31 CT - abdomen, pelvis
      • Cholangiocarcinoma at left lobe liver with metastasis in right ovary, metastatic lymph nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space, and lung metastases show stable disease.
    • 2020-12-24 CT - abdomen, pelvis
      • Imaging Report Form for Cholangiocarcinoma: T2N2M1, stage IV
    • 2020-03-05 Pathology at TMUH
      • colonoscopy biopsy - showing adenocarcinoma (CK7+, CDX2-, P40-, CD20-, ER-, PR-, PA8X-)
  • surgical operation
    • 2020-02-20 T-colostomy and intra-abdominal tumor excision
  • lab data
    • CEA
      • 2022-04-20 4.42 ng/mL
      • 2022-03-29 5.37
      • 2022-03-09 5.56
      • 2022-02-11 6.65
      • 2021-11-23 18.18
      • 2021-10-26 19.05
      • 2021-09-24 15.90
      • 2021-08-17 14.77
      • 2021-07-20 14.81
      • 2021-06-22 14.92
      • 2021-05-24 12.44
      • 2021-04-13 9.68
      • 2021-03-17 9.98
      • 2021-02-17 9.07
      • 2021-01-20 8.42
      • 2020-12-23 8.64
      • 2020-11-10 10.77
      • 2020-10-14 9.25
    • CA125
      • 2022-04-20 350.9 U/mL
      • 2022-03-29 386.6
      • 2022-03-09 329.8
      • 2020-12-23 26.8
      • 2020-11-10 26.2
      • 2020-10-14 26.7
    • CA199
      • 2022-04-20 120.56 U/mL
      • 2022-03-29 113.47
      • 2022-03-09 119.88
      • 2022-02-11 130.83
      • 2021-11-23 237.10
      • 2021-10-26 195.89
      • 2021-09-24 154.07
      • 2021-08-17 125.27
      • 2021-07-20 92.50
      • 2021-06-22 89.58
      • 2021-05-24 72.72
      • 2021-04-13 73.86
      • 2021-03-17 72.85
      • 2021-02-17 56.65
      • 2021-01-20 51.93
      • 2020-12-23 46.93
      • 2020-11-10 55.32
      • 2020-10-14 51.87
  • radiotherapy
    • 2021-12-01 ~ 2022-01-04 RT to the ovarian metastases: 50 Gy/ 25 fx completed
  • chemoimmunotherapy
    • 2022-03-03 ~ undergoing - gemcitabine + carboplatin
    • 2021-08-23 ~ 2021-11-11 - FOLFOX (5-Fu + oxaliplatin)
    • 2021-06-22 ~ 2021-08-17 - PXL-249145 (CAL056 mesylate 20mg/tab) 2# QDAC PO
    • 2021-05-25 ~ 2021-05-26 - PXL-249145 (CAL056 mesylate 20mg/tab) 2# QDAC PO
    • 2021-04-27 ~ 2021-05-11 - PXL-249145 (CAL056 mesylate 20mg/tab) 2# QDAC PO
    • 2020-08-28 ~ 2021-03-16 - Gemcitabine 1000 mg/m2 and Carboplatin AUC 2 on 2020-08-28, -09-11, -09-24, -10-08, -10-20, -11-03, -11-11, -11-30, -12-09, -12-25, -12-31, 2021-01-13, -01-20, -02-03, -02-17, -02-24, -03-09, -03-16.
      • The cisplatin was shifted to carboplatin due to elevated level of creatinine upto 1.5 (eGFR down to 37 mL/min/1.73 m2) on 2020-08-27.
      • Best response: SD.
      • Discontinuation: PD in liver. (PD date:2020-12-24)
    • 2020-03-17 ~ 2020-08-13 - Gemcitabine 1000 mg/m2 and Cisplatin 30 mg/m2 on 2020-03-17, 03-24, 04-07, 04-14, 04-28, 05-05, 05-19, 05-26, 06-09, 06-17, 07-02, 07-09, 08-03, 08-13.
      • Best response: SD.
      • Discontinuation: The creatinine level was increased during regular lab test. (PD date: nil)

[assessment]

  • This patient diagnosed with cholangiocarcinoma (in early 2020) has previously undergone T-colostomy and intra-abdominal tumor excision (2020-02), [gemcitabine + cisplatin] (2020-03 ~ 2020-08), [gemcitabine + carboplatin] (2020-08 ~ 2021-03), CAL056 (2021-04 ~ 2021-08), FOLLFOX (2021-08 ~ 2021-11), RT (2021-12 ~ 2022-01), and is now on [gemcitabine + carboplatin] (2022-03 ~ undergoing).
  • Following consecutive CT scans conducted over the past 12 months, the disease appeared to be mildly advancing unidirectionally.
  • Both RBC and HGB have rebounced (3.72 (2022-05-06) <- 3.12 (2022-05-04), 10.3 (2022-05-06) <- 8.6 (2022-05-04), respectively). In the blood lab, sodium (134 mmol/L), potassium (3.2 mmol/L), and magnesium (1.3 mg/dL) levels were low (2022-05-04). MgSO4 10% 20mL IVD QD has been prescribed.

701345193

220506

{ovarian clear cell carcinoma stage IA}

[objective]

  • exam finding
    • 2022-03-17 Gynecologic ultrasonography
      • No obvious uterine or ovarian lesion
    • 2021-12-06 Patho
      • debulking surgery
        • total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymphnode dissection
      • Diagnosis
        • Ovary, right, oophorectomy - clear cell carcinoma; AJCC 8th edition: pStage IA, pT1aN0(if cM0); FIGO stage: IA
        • Ovary,left, oophorectomy - Endometrioma
        • Histologic Type: Clear cell carcinoma
        • IHC: Napsin A(focal +), PAX8(+), WT-1(-), p53(wild type), and PR(-).
        • Histologic Grade: Clear cell carcinoma is not graded.
    • 2021-11-03 CT
      • Cystic adenocarcinoma of the left ovary is suspected.
      • Small ground-glass opacity 3.5 mm in LLL of the lung, nature?
      • The differential diagnoses include primary lung cancer, metastasis, or benign lesion?
  • lab data
    • S-GPT/ALT
      • 2022-05-05 71 U/L
      • 2022-04-28 47 U/L
      • 2022-04-21 66 U/L
      • 2022-04-06 58 U/L
      • 2022-03-24 29 U/L
      • 2022-03-09 38 U/L
      • 2022-02-24 33 U/L
      • 2022-02-15 38 U/L
      • 2022-01-25 26 U/L
      • 2022-01-13 34 U/L
      • 2021-12-23 39 U/L
      • 2021-12-01 17 U/L
  • surgical operation
    • 2021-12-03 debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + Bilateral Pelvic Lymphnode Dissection) + enterolysis
  • chemotherapy
    • 2022-01-04 ~ undergoing - paclitaxel + carboplatin

==========

2022-05-06

  • S-GPT/ALT has been elevated above the normal range since April 2022
    • 2022-05-05 71 U/L
    • 2022-04-28 47 U/L
    • 2022-04-21 66 U/L
    • 2022-04-06 58 U/L
    • 2022-03-24 29 U/L
    • 2022-03-09 38 U/L
    • 2022-02-24 33 U/L
    • 2022-02-15 38 U/L
    • 2022-01-25 26 U/L
  • The infusion of 3-hour infusion paclitaxel in the current regimen might have to be adjusted to 135 mg/m2 if ransaminases less than 10 times ULN and bilirubin levels are 1.26 to 2 times ULN.

2022-04-12

  • For this ovarian clear cell carcinoma stage IA patient, IV platinum-based therapy could serve as preferred first-line treatment, specifically speaking paclitaxel + carboplatin Q3W, this is just the treatment the patient receiving now, as from early Jan 2022.
  • The patient tolerates the current regimen well according to nursing notes. Alternatively, albumin-bound paclitaxel may be considered if the patient experiences hypersensitivity to paclitaxel.
  • Three months after the debulking surgery on 2021-12-03, a gynecologic ultrasonography on 2022-03-17 found no evidence of uterine or ovarian lesions. So far, so good.

2022-01-26

  • for this ovarian clear cell carcinoma stage IA patient, IV platinum-based therapy could serve as preferred first-line treatment, specifically speaking Paclitaxel + Carboplatin Q3W, this is just the treatment the patient receiving now, as from early Jan 2022.
  • if patient experienced a hypersensitivity reaction to paclitaxel, then albumin-bound paclitaxel might be considered as an alternative.
  • no apparent intolerence observed during this hospitalization.
  • no issue found in active medication.

701374584

220506

[objective]

  • exam finding
    • 2022-05-05 CT - abdomen, pelvis
      • Massive ascites.
      • Swelling of pancreas.
      • General subcutaneous edema.
    • 2022-05-05 KUB
      • Some calcifications in pelvic cavity.
      • Presence of ileus.
      • Intact bony structure(s).
    • 2022-05-05 Chest PA erect view
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.

[assessment]

  • Items in active problem list were treated with corresponding agents
    • metabolic acidosis - sodium bicarbonate
    • hyperkalemia - calcium polystyrene sulfonate
    • hypertension - nifedipine, clonide, doxazosin, carvedilol
    • type II diabetes - linagliptin, repaglinide
  • Beta-blockers can potentially increase blood glucose concentrations and antagonize the action of oral hypoglycemic drugs, however the odds are greater for selective beta blockers than for carvedilol. reference: https://cardiab.biomedcentral.com/articles/10.1186/s12933-019-0967-1
  • There are no records of drug allergies in the database. There are no issues with the current medication.

701096428

220505

[objective]

  • exam finding
    • 2022-04-11 CT - abdomen, pelvis
      • Indication: Right ovarian cancer, pT2bN0; stage IIB; FIGO stage IIB post Debulking surgery s/p C/T with BEP recurrence s/p Debulking surgery on 2021/10/25
      • Abdominal CT with and without enhancement revealed:
        • s/p ATH and BSO.
        • Soft tissue mass at right pelvic floor up to 3.44*1.65cm in largest dimension. In comparison with CT dated on 2021-10-04, the lesion regressed.
        • s/p drainage tube placement at pelvis is found.
        • Wall thickening of the urinary bladder is found.
        • One cystic change at splenic tip up to 0.6cm in largest dimension is found. Stable. Simple cyst is considered.
        • Calcified coronary arteries is found.
        • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
        • Suggest clinical correlation
      • IMp:
        • Right ovarian cancer s/p BSO and ATH with recurrence s/p dubulking surgery. Residual soft tissue mass at right pelvis side wall. In regression.
        • Wall thickening of the urinary bladder, post op. change? Ovarian seeding at bladder out-layer? Suggest closely follow up.
    • 2022-02-18 Chest PA erect view
      • Atherosclerotic change of aortic arch
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • 2021-10-26 Patho - soft tissue tumor, extenstive resection
      • S2021-14976:
        • Soft tissue, pelvic, excision — consistent with recurrent malignant ovarian sex cord tumor
      • F2021-420:
        • Soft tissue, pelvic, excision — consistent with recurrent malignant ovarian sex cord tumor
    • 2021-10-25 Frozen section
      • Preliminary diagnosis:
        • Soft tissue, pelvic, biopsy — consistent with recurrent malignant tumor
    • 2021-10-12 Whole body PET scan
      • An inhomogenous glucose hypermetabolic lesion in the right posterior lower pelvic cavity. A recurrent tumor should be considered.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
      • Increased FDG uptake in bilateral masseter muslces and increased FDG accumulation in the colon, rectum, both kidneys and bilateral ureters. Physiological FDG uptake/accumulation is more likely.
    • 2021-10-04 CT - abdomen, pelvis
      • S/P hysterectomy. A soft tissue lesion (3.6x5.4cm) at right pelvic cavity with some cystic component suspected tumor recurrence.
    • 2021-08-16 Patho - soft tissue debridment
      • Skin and soft tissue, left anterior thigh., fasciectomy — Necrosis and acute inflammation.
    • 2021-08-13 CT - left femur
      • Abscess formation at left anterior thigh (vastus medialis muscle)and iliopsoas muscle
      • Cellulitis of left thigh
      • Post-OP change of pelvis with a mass lesion in right perirectal region.
    • 2021-05-20 Patho - soft tissue tumor, extensive resection
      • pathologic diagnosis
        • Ovary right, debulking surgery — Compatible with malignant ovarian sex cord tumor
        • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy
        • Soft tissue, pelvic, debulking surgery — Metastatic tumor
        • AJCC 8 th edition, Pathology stage: pT2bN0; stage IIB; FIGO stage IIB
      • microscopic examination
        • Histologic Type: Compatible with malignant ovarian sex cord tumor
        • Histologic grade: High grade
        • Regional Lymph Nodes: All lymph nodes negative for tumor cells
          • number of lymph node examined: 4 (left iliac), 1 (left obturator), 4 (right iliac), 1 (right obturator)
        • Pathologic Stage
          • Primary Tumor: pT2b (tumor extension and/or implants on other pelvic tissues)
          • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
          • Distant Metastasis: Not applicable
        • Specimen labled “pelvic tumor”: Compatible with malignant ovarian sex cord tumor with pelvic seeding
        • IHC: WT1(+), CAM 5.2(+), CK(-), Inhibin(-), CD117(focally weakly+), DOG1(-), Desmin(-), Smooth mucle actin(-), CD34(-), S100(-), MDM2(-), STAT6(-)
    • 2021-05-19 Frozen section
      • Ovary right, frozen section — Favor malignant (pleomorphic epitheloid tumor cells with necrosis), tumor nature wait for paraffin section
    • 2021-05-13 Gynecologic ultrasonography
      • suspected pelvis mass > 25cm, malignancy can not be ruled out
  • surgical operation
    • 2021-10-25
      • operation
        • Excision of pelvic cancer
        • HIPEC
        • IOUS
        • Tenckhoff insertion     - finding
        • s/p midline incision
        • Adhesion of small bowel was encountered.
        • IOUS: a recurrent ovarian cancer in the pelvic cavity adjacent to rectum
        • Pathologic report of frozen section: malignancy
        • HIPEC regimen: Lipodox 30mg/m^2 + Carboplatin AUC 5
        • Drain: 15 Fr Blake drain x 1 in the pelvic cavity
        • Tenckhoff catheter from RLQ
    • 2021-10-25
      • surgery
        • Debulking surgery + adhesiolysis     - finding
        • Supraumbilical midline vertical skin incision
        • Uterus: s/p hysterectomy
        • Adnexa: s/p Bilateral Salpingo-oophorectomy
        • CDS: adhesion with intestines
        • Moderate adhesion between omentum, small & large intestines and CDS
        • A 5x4 cm mass at right pelvic cavity with cystic component, beside the rectum.
        • s/p bilateral cystoscopic catheterization insertion before the operation
    • 2021-08-13
      • surgery
        • Deep debridement + fasciectomy + primary closure
      • finding
        • An abscess with necrotizing fasciitis and gas gangrene is found about 10*20cm in size over the left anterior thigh.
    • 2021-05-19
      • operation
        • enterolysis
        • excision of intraabdominal tumor
      • finding
        • s/p hystectomy
        • a bulky tumor mass in pelvic cavity with adhesion to small bowel and rectum
        • several bleeders in pelvic wall
    • 2021-05-19
      • surgery
        • Pelvic tumor, suspect malignancy
        • Frozen: sarcoma
        • Debulking surgery (tumor excision + pelvic lymph nodes dissection+ Cytoreduction surgery + infracolic omentectomy )        
      • finding
        • Supraumbilical midline vertical skin incision
        • Uterus: s/p hysterectomy
        • Adnexa: pelvic tumor 10*10 cm, invasion to posterior pelvic wall, intra-op rupture(+)
        • CDS: invisible due to tumor mass occupied
        • Ascites: bloody , about 500 ml
        • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
        • Omentum: normal appearance, infracolic omentectomy was done.
        • Liver: grossly normal & smooth
        • Appendix: grossly normal.
        • After the operation, suboptimal debulking surgery was achieved.
        • Residue tumor: multiple tumors, maximal diameter more than 1 cm, over rectum and peritonealwall and bladder base
  • chemotherapy
    • 2022-05-05 - paclitaxel + cisplatin
    • 2022-04-19 - paclitaxel
    • 2022-04-12 - paclitaxel + cisplatin
    • 2022-03-16 - paclitaxel
    • 2022-03-09 - paclitaxel + cisplatin
    • 2022-02-16 - paclitaxel
    • 2022-02-08 - paclitaxel + cisplatin
    • 2022-01-13 - paclitaxel
    • 2022-01-05 - paclitaxel + cisplatin
    • 2021-12-24 - paclitaxel
    • 2021-12-16 - paclitaxel + cisplatin
    • 2021-11-22 - paclitaxel + cisplatin
    • 2021-10-23 - liposome doxorubicin + carboplatin
    • 2021-09-22 - bleomycin
    • 2021-09-13 - bleomycin + etoposide + cisplatin
    • 2021-07-14 - bleomycin + etoposide + cisplatin
    • 2021-07-01 - bleomycin
    • 2021-06-24 - bleomycin
    • 2021-06-17 - bleomycin + etoposide + cisplatin (BEP)

==========

2022-05-05

  • The CT (2022-04-11) showed a residual soft tissue mass over the right pelvis side wall in regression, as well as a thickening of the bladder wall. At least a partial response was achieved by the current regimen [paclitaxel + cisplatin] so far.
  • The blood concentrations of cations have remained relatively low in recent months. Mg 1.4 mg/dL, K 3.8 mmol/L, Na 134 mmol/L (2022-05-03), Ca 2.01 mmol/L (2022-04-18). Following administration of magnesium sulfate injections, Mg rebounded to 2.0 mg/dL on 2022-05-05.
  • Poor control of blood sugar levels. A record of 422 mg/dL was obtained 2022-05-05 07:33, one hour after 8 units of insulin actrapid were administered. No HbA1c data found in recent 3 months.
  • The last “acute embolism and thrombosis of unspecified deep veins of lower extremity” was diagnosed in cardiology OPD on 2021-11-19. There is no cardiology follow-up record since then, so it is unclear if the thrombosis risk remains for the purpose of determining the need for edoxaban.

2022-04-08

  • Systemic therapy regimens for patients with recurrent advanced sex cord stromal tumors might include paclitaxel + carboplatin, EP (etoposide + cisplatin), or BEP (bleomycin + etoposide + cisplatin). The patient had received BEP from June to September 2021 and has been receiving paclitaxel + cisplatin since November 2021.
  • The last three consecutive analyses of body fluid cytology (ascites, on 2022-02-18, 2022-03-14, 2022-03-18) after debulking surgery with HIPEC (2021-10-25) did not reveal granuloma or malignancy. Regarding the cancer, so far, not bad.
  • Low serum magnesium level (1.6mg/dL on 2022-04-06) has been managed with prescribed magesium sulfate injection, however, high blood sugar reading (359mg/dL at 17:23 on 2022-04-07) should be monitored closely to determine whether a hypoglycemic agent is needed.

701113992

220504

[objective]

  • diagnosis
    • Esophagus cancer (Squamous cell carcinoma) with right middle lobe lung metastasis, cT4bN2M1, stage IVB, s/p Tr and jejunostomy on 2022-02-18
  • exam finding
    • 2022-05-03 Chest PA/AP view
      • Ground glass opacity in RUL.
    • 2022-04-18 Abdominal Ultrasonography
      • liver parenchyma disease (incomplete exam of liver)
      • bilateral renal cysts
      • pancreas obscured
      • left pleural effusion
    • 2022-04-06 Chest PA/AP view
      • S/P tracheostomy
      • S/P port-A implantation.
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Spondylosis of the T-spine
      • Blunting of bilateral costal-phrenic angle is noted, which may be due to pleura effusion?
      • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
      • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
    • 2022-03-26 MRI - brain
      • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1W FLAIR, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) and cerebral TOF MRA reveal:
        • General enlargement of cistern spaces and cortical sulci, indicating general brain atrophy.
        • Dilatation of ventricles, periventricular T2-hyperintense caps and flattening corpus callosum, indicating hydrocephalus.
        • Diffuse T2-hyperintensities in periventricular deep white matters, indicating leukoaraiosis.
        • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
        • No midline shift, nor space-occupying lesion.
        • No remarkable finding of skull base and bony structures.
        • No remarkable finding of bilateral orbital contents and optic nerves.
        • No remarkable finding of nasopharynx visible in these images.
        • Diffuse luminal irregularity with mild segmental stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
      • IMP:
        • General brain atrophy.
        • Hydrocephalus.
        • Leukoaraiosis.
        • Intracranial artherosclerosis.
    • 2022-03-24 ENT hearing test
      • Tymp:
        • R’t type A; L’t type Ad.
      • ART:
        • Bil absent.
      • PTA
        • Reliability FAIR TO POOR
        • Average RE 63 dB HL; LE 65 dB HL.
        • Bil moderate to profound mixed type HL.
    • 2022-03-23 Nasopharyngoscopy
      • Rt. side tympanic membrane was in pattern of post tympanoplasty
      • Lt. side atrophic scar
    • 2022-03-16 Tc-99m MDP whole body bone scan
      • Increased radioactivity in the sternum, the nature is to be determined (post-traumatic change or other nature?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in the right rib cage, some lower C-, upper T- and L2-5 spines, bilateral sternoclavicular junctions, shoulders, right S-I joint, and knees.
    • 2022-02-16 Patho - esophageal biopsy
      • Esophageal tumor, 20-25 cm below incisors, biopsy — Squamous cell carcinoma
      • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by solid tumor cell nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with focal necrosis.
      • Immunohistochemical stains of CK(+); P16(-), P63(+) and P53 (+, scant) for tumor.
    • 2022-02-15 CT - lung/mediastinum/pleura
      • advanced lower cervical esophageal cancer or Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases d/d includes large conglomerated metastatic LAP.
      • LLL pneumonia and RML metatasis of lung.
    • 2022-02-15 Esophagogastroduodenoscopy
      • Diagnosis:
        • Highly suspect esophageal cancer, 20-25cm below the incisor, s/p biopsy
        • Esophageal stenosis, 20cm below the incisor
        • Gastric subepithelial lesion, fundus
        • Superficial gastritis
      • Suggestion:
        • Pursue pathology result
    • 2022-02-15 Bronchoscopy
      • Bronchoscopic diagnosis:
        • Upper airway external compression over upper trachea
        • left lower lobe bronchus: sputum impaction s/p bronchoscopic sunction
    • 2022-02-14 Esophagogastroduodenoscopy
      • Esophagus:
        • Luminal stenosis with acute angle was noted at 20cm below the incisor, suspect external compression. The endoscopy could not pass through it.
      • Diagnosis:
        • Esophageal stenosis, 20cm below the incisor, suspect external compression by left neck mass
      • Suggestion:
        • arrange CT: neck ~ chest
        • If EGD was indicated, slim-caliber scope is needed
    • 2017-05-25 Pelvis - THR
      • Marked disk space narrowing with spurs formation at L3-L4, L4-L5 levels due to spondylosis
  • consultation
    • 2022-04-14 Rehabilitation
      • Dx: Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases d/d includes large conglomerated metastatic LAP. LLL pneumonia and RML metatasis of lung
      • swallowign evaluation
        • no drooling
        • no choking with 3cc water
        • tongue ROM: intact
        • tongue muscle power : fair
        • delayed reflex (prolonged oral holding)
        • hyoid bone elevation: fair.
        • foreign body sensation during swallowing
        • no dyspnea upon examination
      • Plan
        • arrange swallowing training
        • consider arrnage PMR Dr. Wu’s OPD follow up for further OPD swallowing trainign program. Maybe arrange VFSS in the future
    • 2022-03-28 Dermatology
      • Q
        • For skin rash & icthing at back
      • A
        • This patient suffered frpm erythematous papules-patches on trunk for days.
        • Imp: Subacute dermatities
        • Suggestion:
          • Sinphardema 1 tubes, bid
          • Topsym cream 5 tubes, bid
          • Zaditen 1, bid
    • 2022-03-23 ENT
      • Q
        • For right ear tinnitus
        • This 85-year-old man, a patient of Eso cancer with Lns mets S/P Tr & J-tube inserted. He was admitted for CCRT. He complained of right ear tinnitus for 2 days. We need expertise to evaluate his condition thanks!
      • A
        • Local finding via scope:
          • Rt. side tympanic membrane was in pattern of post tympanoplasty
          • Lt. side atrophic scar
        • The tinnitus may be due to chemotherapy
        • We’ll arrange PTA exam this afternoon, thanks for your consultation.
    • 2022-03-09 Rehabilitation
      • Assessment
        • respiratory failure s/p intubation
        • advanced lower cervical esophageal cancer or Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • W5 starts with standing balance training. caregiver transfer skills training. next W1 ambulation trianing.
      • Goal
        • Recondition, improve endurance and muscle strength
    • 2022-02-17 General and Gastroenterological Surgery.
      • Q
        • This time, he was admitted to MICU for treatment of hypercapnea respiratory failure post intubation with ventilator since 20220214. After admission, NG tube insert was done but failure. Dut to long term NPO status, so we need your help for TPN nutrition supply, thanks !
      • A
        • obj?
          • A case of esophageal cancer with obstruction who request nutrition support.
          • General appearance: ill looking
          • GI tract: Dysphagia (+), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (+), Poor digestion (-), BW loss (-) , stool (+), Bowel sound (+)
          • Feeding: NPO (NG tube insert failure)
          • Allergy: NKA
          • Nutrition assessment: BH 172cm, BW 57.8kg, IBW 65kg, 89% IBW, BMI 19.5, BEE (calculated based on IBW) 1246kcal, TEE 1943kcal
          • Lab data: Alb 2.9, BUN 26, Cr 0.58, Na 133, K 3.6, BS 100
          • According to the patient’s present conditions, parenteral nutrition will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
        • PN suggestion:
          • F/U preAlb. ALP. rGT. T/D Bil GOT GPT TG
          • DC Bfluid 1000ml QD
          • SMOFkabiven central 1477ml QD, 61.5ml/hr
          • Lyo-Povigent 4ml/QD (add in TPN) (if out of stock, then use B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
          • Addaven 10ml/QD (add in TPN)
          • Total fluid 30-40ml/kg/day (2000-2500ml/day)
          • Feeding gastrostomy or feeding jejunostomy ASAP
        • PN monitor items
          • Check BW QW5 and record I/O Q8H
          • Check one touch Q6H for 2days, if stable QD check
          • Please control BS < 200 mg/dl with RI sliding scale
          • QW1 check CBC/DC
          • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
          • if TPN not sufficient, use YF5 or D10W instead.
        • postscript
          • 20220218 op, on feeding gastrostomy or feeding jejunostomy
          • 20220218 Sent to OR DC TPN, post-op PPN supply and try EN as soon as possible.
    • 2022-02-16 Radiation Oncology
      • Assessment
        • Suspicious advanced lower cervical esophageal cancer or cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases.
      • Plan
        • Radiotherapy can be considered for this patient if positive pathology report available and his condition stable (including respiration such as if s/p tracheostomy). Further discussion in tumor board (20220218).
    • 2022-02-16 Thoracic Surgery
      • Q
        • For tumor excision and tracheostomy
        • This 85-year-old male who had past history of: 1) BPH; 2) Thyroid cancer with squsamous cell carcinoma (Cheng Hsin general hospital in 20211126 report).
        • According to the description of the patient’s family and medical record. He suffered from poor appetite and general weakness since 2021-12, he went to VGHTPE and left neck neoplasm was noted by CT. Panendoscopy showed one protruding ulcerative lesion with luminal narrowing and easily contact bleeding was noted at 20 to 21 cm of incisor. The ordinary scope could not pass through the stenosis and we then shifted to nasoendoscope. Biopsy was done on 20220110 and pending biopsy result.
        • This time, progressive shortness of breath and fever intermittently since 20220210, he was sent to our ER for help. At ER, his consciousness clear, marked dyspnea with desaturation, stridor and left decreased breath sound were noted. ABG analysis showed CO2 retension (PaCO2: 61.8 -> 85.8 mmHg). Emergency intubation with ventilator was done. He was admitted to MICU for treatment of 1) hypercapnea post intubation with ventilator; 2) Suspect esophageal cancer survey.
        • After admission, keep on ventilator support. EGD was done which showed Esophageal stenosis, 20cm below the incisor, suspect external compression by left neck mass. Chest CT showed advanced lower cervical esophageal cancer or Cervithorocic junction esophageal cancer with extensive adjacent structures involvement and regional LNs metastases d/d includes large conglomerated metastatic LAP. LLL pneumonia and RML metatasis of lung. So we need your help for tumor excision and tracheostomy evaluation, thanks!
      • A
        • I have visited the patient and reviwed the images. If his family agree treatment, I will arrange tracheostomy, port-A and feeding jejunostomy. Thanks for your consultation!!
    • 2022-02-14 Anesthesiology
      • Q
        • For difficult intubation
          • This 85 y/o male patient had history of suspect esophageal cancer.
          • This time, he was admitted to MICU for hypercapnea with respiratory failure post intubation with ventilator. After admisison to MICU, irritable and dyspnea, stridor were noted. so we change endotracheal tube but difficult intubation, so we need your help, thanks!
      • A
        • We were consulted for emergent intubation.
        • A #6.5 ETT was placed via McGrath and fiber-scope fixed at 25cm.
        • Bil. breathing sounds were noticed equally.
        • SpO2 was 99-100% after the procedure.
        • Please f/u CXR.
  • surgical operation
    • 2022-02-18 tracheostomy + port-A + jejunostomy
      • 7.0mm ID, 120mm length bivona tracheal tube in place
      • 8Fr. polysite port-A via right cephalic vein
      • 18 Fr. jejunosotmy tube

[assessment]

  • The patient is an elderly male suffering from esophageal cancer (squamous cell carcinoma) with RML lung mets following tracheostomy and jejunostomy (Op on 2022-02-18).
  • The advanced age could necessitate shared decision-making prior to cancer-specific treatment, taking into account the patient’s overall life expectancy. Alternatively, the following regimen in combination with RT might also be considered:
    • Paclitaxel + carboplatin
    • Fluorouracil + oxaliplatin
    • Fluorouracil + cisplatin
  • The S-GPT/ALT level was normal in early 2022-04, rose above 50 U/L on 2022-04-11 and reached 113 U/L on 2022-05-03. No hepatitis virus lab data were found. During that period, no medications other than herbal medicine were prescribed according to in-hospital records. Access to NHI-PharmaCloud is not authorized. Further study might be needed.
  • There could be a decrease in ventilation efficiency due to lung mets, making oxygenation more important. Lab data showed RBC 3.62*10^3/uL and HGB 10.8g/dL on 2022-05-03, both below normal limits. There might be a need for monitoring.
  • Pneumonia at RUL is treated with Tapimycin 4.5g IVD Q6H currently.

700167626

220503

  • There is only one item remaining on the list of current active problems: fever with UTI since 2022-04-29.
  • Escherichia coli 33000 CFU/cc were found in urine culture, and Staphylococcus epidermidis were found in blood culture.
  • Following administration of Flumarin (flomoxef) 1000mg IVD Q12H since 2022-04-29, the patient’s temperature became stable on 2022-05-02 afternoon, and no higher than 37 degrees Celsus observed so far.
  • Underlying diseases are managed with corresponding medicine.

701186882

220503

[objective]

  • This 43 years old female patient has the history of: 1) Chronic kidney disease for 10 years; 2) Ulcerative colitis with medical treatment for 20 years; 3) Fourth degree hemorrhoids status post hemorrhoidectomy on 20210623; 4) Left arteriovenous fistula on 20220124.

  • diagnosis

    • chronic kidney disease, stage 5
    • anemia, unspecified
    • ulcerative colitis without complications
    • fever, unspecified
  • exam finding

    • 2022-05-02 Abdominal Ultrasonography
      • Parenchymal renal disease
      • Renal cyst, right
      • Gallbladder sludge
      • Minimal ascites
    • 2022-03-08 Abdominal Ultrasonography
      • Parenchymal renal disease
    • 2021-11-19 Renal ultrasound
      • Chronic renal parenchymal disease, advanced degree
    • 2021-06-23 Patho - hemorrhoids
      • Anus, hemorrhoidectomy — hemorrhoid
      • Microscopically, it shows dilatation of venous plexus with congestion.
  • lab data

    • 2022-03-11
      • HSV 1 IgG positive
      • HSV 1 IgG Value 53.6 RU/mL
      • HSV 2 IgG negative
      • HSV 2 IgG Value < 0.50
      • HSV 1 IgM negative
      • HSV 1 IgM Value 0.05
      • HSV 2 IgM negative
      • HSV 2 IgM Value 0.08
    • 2022-03-10
      • EB VCA IgA positive
      • EB VCA IgA Value 1.9
      • EB VCA IgG positive
      • EB VCA IgG Value 8.6
      • Toxoplasma IgG negative IU/mL
      • Toxoplasma IgG Value 0.2 IU/mL
      • Toxoplasma IgM negative
      • Toxoplasma IgM-index 0.05
      • HLA A 11
      • HLA A 24
      • HLA B 60
      • HLA B 61
      • HLA C 9
      • HLA C 10
    • 2022-03-09
      • EB VCA IgM negative
      • EB VCA IgM Value 0.0
      • VZV IgM negative
      • VZV IgM Value 0.1
      • CMV_IgG Reactive
      • CMV_IgG Value 937.1 AU/mL
      • CMV IgM Nonreactive
      • CMV IgM Value 0.19 Index
    • 2022-03-08
      • VZV IgG positive
      • VZV-G Value 3.1
    • 2022-02-22
      • Thyroglobulin 12.95 ng/mL
    • 2022-02-21
      • RPR/VDRL Nonreactive
      • RH(D) Positive
      • Blood type ABO O
      • HBsAg Nonreactive
      • HBsAg (Value) 0.28 S/CO
      • Anti-HBc Nonreactive
      • Anti-HBc-Value 0.14 S/CO
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.08 S/CO
      • Anti HTLV I/II Nonreactive
      • Anti HTLV I/II Value 0.06 S/CO
      • HIV Ab-EIA Nonreactive
      • Anti-HIV Value 0.05 S/CO
      • Anti-HBe S/CO
      • Anti-HBe Nonreactive
      • Anti-HBe Ratio 1.56 S/CO
      • Anti-HBs 376.18 mIU/mL
      • HBeAg(EIA) S/CO
      • HBeAg Nonreactive
      • HBeAg(Value) 0.362 S/CO
      • RF <10 IU/mL
      • CA125 14.8 U/mL
      • CA153 7.7 U/mL
      • CA199 34.20 U/mL
      • CEA 3.62 ng/mL
      • AFP 2.1 ng/mL
    • 2020-05-14
      • ANA Negative
    • 2020-05-13
      • Zinc,Zn 621 ug/L
    • 2020-05-11
      • Anti-ENA SS-A(Ro) 0.4 EliA U/ml
      • Anti-ENA SS-B(La) 0.4 EliA U/ml
      • TPHA <1:80
    • 2020-05-08
      • RPR/VDRL Nonreactive
      • Ferritin 105.3 ng/mL
      • T3 0.88 ng/dL
      • TSH 1.373 uIU/mL
      • Free-T4 0.80 ng/dL
      • Ferritin 110.1 ng/mL
  • surgical operation

    • 2022-01-24 Creation of LT wrist AVF        
      • Left Radial Artery: Calcification(-), Diameter(2.3)mm
      • Cephalic Vein: Stenosis(-), Fibrosis(-),Transpostion(-),Diameter(3.0)mm
      • Anastomosis of Left Radial artery & cephalic vein with 7-0 prolene.   
    • 2021-06-23 Hemorrhoidectomy        
      • Prolasped hemorrhoids at 3,7,11 o’clock        
      • Easy bleeding, Naldebain

[assessment]

This patient has CKD stage 5 adminitted on 2022-04-29

CKD stage 5, high Creatinine, high BUN, high phosphorus, low calcium, low bicarbonate normal CRP and WBC AV shunt

701361784

220429

[objective]

  • exam finding
    • 2022-03-27 Chest
      • Lung markings: emphysematous change in the bilateral lung fields
    • 2022-03-26
      • Fecal material store in the colon.
      • Spondylosis of the L-spine is noted.
    • 2022-03-26 Femur LT
      • Left femoral intersubtrochanteric fracture, s/p ORIF
    • 2022-03-14 Chest
      • Atherosclerosis of the aorta.
    • 2022-03-08 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen, stomach and bones/bone marrow (stage IV).
    • 2022-03-07 Bone densitometry - hip
      • Right hip, BMD is 0.537 gms/cm2, about 2.8 SD below the peak bone mass (63%) and 0.3 SD below the mean of age-matched people (95%).
      • Osteoporosis
    • 2022-02-25 Patho - lymphnode biopsy
      • pathologic diagnosis
        • Left subhepatic lesion, CT-guide biopsy — High grade B cell lymphoma, favor diffuse large B-cell lymphoma
      • microscopic examination
        • Histology type: high grade B cell lymphoma shows medium to large atypical lymphoid cells with nucleoli, frequent apoptosis and focal tumor necrosis.
        • Immunohistochemistry: CK(-), CD3(-), CD20(+), Bcl-2(-), CD30(-), CD10(+), Bcl-6(+), C-MYC(+, 80%), cyclin-D1(-) and Ki-67:>90% for tumor. According to all above histopathologic findings, it is in favor of diffuse large B-cell lymphoma, and Burkitt’s lymphoma is less likely, but can not be entirely excluded due to limited specimen.
    • 2022-02-18 MRI - liver, spleen (non-contrast)
      • Non-contrast MRI has limitation in diagnosis of solid organ pathology, bowel loop lesion, and vascular system abnormality. We recommend contrast enhanced MRI if patient’s renal function can tolerate Gd-DTPA injection.
        • There are several lobulated soft tissue masses in the hepatic hilum, gastrohepatic ligament, hepatoduodenal ligament, aortocaval space, and right perirenal space. In addition, One enlarged node measuring 1.9 x 1.4 cm in right supradiaphram cardiac-phrenic space is noted. Three soft tissue masses in the omentum are noted. Malignant lymphoma is highly suspected.
        • There is a well-defined heterogeneous mass measuring 5 x 3.2 cm in the submucosal layer of the gastric body that may be lymphoma. Please correlate with gastroscopy.
        • There is edematous wall thickening and distension of the gallbladder, and mild dilatations of IHDs and CHD. Please correlate with clinical condition.
        • Both kidney show small size and thin renal parenchyma that are compatible with chronic renal disease. Please correlate with renal function.
        • Mild ascites is noted.
        • Mild right side pleura effusion is noted.
        • There is no focal abnormality in the pancreas and spleen.
        • The abdominal aorta and IVC are grossly unremarkable.
      • Malignant lymphoma is highly suspected. Please correlate with biopsy and serum LDH level.
  • lab data
    • 2022-02-17
      • Anti-HBc reactive, 4.57 S/CO
      • Anti-HCV nonreactive, 0.10 S/CO
      • HBsAg nonreactive, 0.34 S/CO
  • consultation
    • 2022-04-19 cardiology
      • Q
        • For hypertension poor control
        • This 72-year-old female, a pt of double-hit DLBCL at troperitoneal fossa, Lugano stage IV Dx in Feb 2022 S/P C/T. She was admitted for chemotherapy. Owing to high blood perssure was noted (195/91 mmHg) and anti-hypertensive agent was given but still poor control. We need expertise to evaluate her condition thanks!
      • A
        • This is a 72 years old lady who was admitted for Diffuse large B cell lymphoma under R-DA-EPOCH therapy. We were consulted for poor control BP
        • Current medication
          • concor 5mg 1# qd
          • hyzaar 1# qd
        • exam
          • BP: 195/91 (most of the day: SBP>160)
          • HR: 80
          • EKG: LVH pattern
          • CXR: normal heart size
          • Cr 2.0
          • UA 10.5;
        • Impression
          • Hypertensive cardiovascular disease with poor cpntrol; suspected C/T induced.
        • Suggestion
          • May add sevikar 1# qd; regular use of apresoline if SBP still >160 mmHg.
          • DC hyzare due to significant hyperuricemia.
          • Check chemotherapy side effect (whether using tyrosine kinase inhibitor? VEGF inhibitor?), and change regimen if feasible.
    • 2022-02-25 cardiology
      • S: abdominal pain
      • O:
        • Labs
          • Cr: 1.75 -> 2.43 -> 1.2
          • CRP: 4
          • Na/K: 136/4.2
        • Cardiac echo: EF: 70%
          • Normal LV systolic function with normal wall motion.
          • Hypertrophic cardiomyopathy without outflow tract obstruction; LV diastolic dysfunction Gr 1.
        • Current BP medications
          • PO concor and po hyzaar
      • Impression:
        • Hypertensive cardiovascular disease, without acute hypertensive crisis
        • Hypertrophic cardiomyopathy without outflow tract obstruction
        • Suspected cholangiocarcinoma or suspected lymphoma
      • Suggestion:
        • Adequate pain control if patient is in pain due to fracture or abdominal pain.
        • Add norvasc 1# qd - bid.
        • to keep concor 5 mg qd
    • 2022-02-23 radiological diagnosis
      • According to the clinical condition and imaging findings, biopsy is indicated.
    • 2022-02-16 surgery
      • a huge tumor near liver hilum, liver origin? pancreatic origin? or lymphoma
        • admission for tumor survey
        • check MRI and tumor markers after admission
        • check HBsAg, anti-HCV, anti-HBs, anti-HBc
  • chemotherapy
    • 2022-03-15 ~ undergoing - R-DA-EPOCH, Dose-adjusted EPOCH-R,
      • etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, plus rituximab
        • https://www.uptodate.com/contents/image?imageKey=ONC%2F88411
        • drugs
          • Rituximab, 375 mg/m2 IV, Day 0 or 1
          • Etoposide, 50 mg/m2 per day IV, Days 1 to 4 (96 hours)
          • Doxorubicin, 10 mg/m2 per day IV, Days 1 to 4 (96 hours)
          • Vincristine, 0.4 mg/m2 per day IV (dose not capped), Days 1 to 4 (96 hours)
          • Cyclophosphamide, 750 mg/m2 IV, Day 5
          • Prednisone, 60 mg/m2 orally twice daily, Administer first dose 30 minutes prior to chemotherapy on day 1., Days 1 to 5
          • Granulocyte colony stimulating factor (G-CSF), Start day 6
      • Pretreatment considerations:
        • Hydration
          • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
        • Emesis risk
          • MODERATE.
        • Prophylaxis for infusion reactions
          • Premedicate with acetaminophen and diphenhydramine, with or without an H2 receptor blocker, 30 minutes prior to at least the first and second infusions of rituximab.
        • Vesicant/irritant properties
          • Doxorubicin and vincristine are vesicants; avoid extravasation. Etoposide is an irritant.
        • Infection prophylaxis
          • Primary prophylaxis with hematopoietic growth factors is an essential component of this regimen. Regular or pegylated G-CSF may be used according to center policy. In addition, due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, consider the use of antimicrobial prophylaxis.
        • Dose adjustment for baseline liver or renal dysfunction
          • Adjustment of initial cyclophosphamide, doxorubicin, etoposide, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of etoposide and cyclophosphamide may be required for renal dysfunction.
        • Hepatitis screening
          • Patients should be screened for hepatitis B and C prior to starting rituximab, and, if positive, considered for antiviral prophylaxis.
        • Cardiac screening
          • Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. Assess baseline LVEF prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation, those with recent myocardial infarction, severe myocardial dysfunction, severe arrhythmia, or previous therapy with high cumulative doses of doxorubicin or any other anthracyclines.
        • CNS prophylaxis
          • The need for CNS prophylaxis is determined based upon the aggressiveness of the tumor reflected in the histology, organ involvement, and presence or absence of high risk features.
        • HIV screening
          • Patients should be screened for HIV prior to starting therapy. Consider reducing the initial dose of cyclophosphamide to 187 mg/m2 if CD4 <100/microL at diagnosis.
        • Neurotoxicity
          • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
      • Monitoring parameters:
        • CBC with differential and platelet count twice weekly during treatment.
        • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
        • Monitor cumulative doxorubicin dose. Reassess LVEF periodically during dose-adjusted EPOCH-R therapy, as clinically indicated.
        • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.

==========

2022-04-29

  • SBP 190~140 (most times > 150), DBP 65~90, HR no less than 100 pulse per minite since 2022-04-28 this hospitalization so far, under Concor (bisoprolol 5mg, QD), Sevikar (amlodipine 5mg + olmesartan 20mg, QD) prescribed as self-carried drugs since 2022-04-29. Chemotherapy has not yet been administered for now in this hospital stay.
  • WBC 310/uL, Neutrophil 18%, CRP 5.24 mg/dL, RBC 2.610^6/uL, HGB 8.0g/dL, PLT 4310^3/uL, normal urine exam results on 2022-04-28, body temperature 39.3 degree Celsius at 07:41 2022-04-29.
  • Primary prophylaxis with hematopoietic growth factors should be a component of the R-DA-EPOCH regimen. Chemotherapy induced cytopenia is managed with Granocyte (lenograstim 250mcg, QD). Elevations of CRP occur in association with acute and chronic inflammation due to a range of causes, including infectious diseases and noninfectious inflammatory disorders. Elevated CRP with fever is managed with Tapimycin (piperacillin 2g + tazobactam 0.25g, Q8H). Due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, the use of antimicrobial prophylaxis might be necessary. reference: https://pubmed.ncbi.nlm.nih.gov/11929754/
  • Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. The baseline LVEF prior to chemotherapy initiation on 2022-02-22 was 70%, this does not suggest a dose alteration.
  • The patient was screened for hepatitis B and C prior to starting rituximab and is now receiving Vemlidy (tenofovir alafenamide 25mg QDCC) for her HBV infection.

2022-04-18

  • Pathology on 2022-02-25 revealed that C-MYC(+, 80%), BCL-2(-), BCL-6(+), high-grade B-cell lymphoma (HGBL) with translocations of MYC and BCL6, also known as double-hit lymphoma, is frequently associated with poor prognostic factors, including elevated LDH, bone marrow and central nervous system involvement, and high IPI score.
  • PET on 2022-03-08 indiated involvement of multiple lymph nodes on both sides of the diaphragm, spleen, stomach and bones/bone marrow, stage IV.
  • DA-EPOCH-R has been in use since 2022-03-15, the LDH has decreased to 181 U/L (2022-04-15, WNL) from its peak of 1364 U/L (2022-03-16), which might hint an improvement, and no evidence of CNS involvement has yet been confirmed.
  • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine. Metoclopramide and sennoside have been prescribed.
  • Hypomagnesemia (1.4 mg/dL 2022-04-18) is treated with MgSO4 10% 20mL IVD QD currently.

700126665

220427

{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}

[objective]

  • exam findings
    • 2022-03-16 CT - abdomen, pelvis
      • Liver metastases S/P C/T show progressive disease.
      • Mechanical small bowel obstruction is noted. However, the transition zone is hard to identify. The differential diagnosis include tumor seeding or adhesion.
      • A soft tissue nodule 5 mm in LUQ omentum is noted that may be tumor seeding. Ascites in right subphrenic space and Morison pouch.
    • 2022-02-08 ultrasound - abdomen
      • Hepatic tumor, nature to be determinated
      • Hepatic cyst, GB stone
    • 2022-01-20 esophagogastroduodenoscopy
      • suspected gastric intestinal metaplasia, antrum and low body, s/p biopsy at antrum, GC
    • 2021-11-30 CT - ABD
      • Post-op at the colon and small bowel loops.
      • RLQ peritoneal soft tissue tumors, suspected carcinomatosis.
      • Newly developed liver tumors, suspected liver metastasis.
      • Liver and renal cysts.
    • 2021-08-03 patho - small intestine resection for tumor
      • mucinous adenocarcinoma, colonic origin
      • IHC: CK7(-), CK20(+), CDX2(+) and GATA-3(-), colonic origin
    • 2021-07-27 whole body PET scan
      • two glucose hypermetabolic lesions in the liver, some glucose hypermetabolic lesions in the abdominal cavity and a glucose hypermetabolic lesion in the umbilicus. metastatic lesions should be considered first.
    • 2021-01-20 patho - colon segmental resection for tumor
      • tumor, transverse colon, SILS left hemicolectomy - mucinous adenocarcinoma - pT3N0 (if cM0), stage IIA
    • 2021-01-19 patho - breast mastectomy with regional lymph nodes
      • breast, right, modified radical mastectomy - invasive carcinoma. grade 2.
      • lymph node, right axilla, lymphadenecomy - metastatic carcinoma.
      • pathology stage: pT2 pN2 (if cM0); anatomic stage: IIIA, pathology prognostic stage: IIIA
    • 2021-01-12 patho - colorectal polyp
      • adenocarcinoma. IHC stain: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    • 2020-12-28 patho - lymphnode biopsy
      • axilla, right, core biopsy - invasive carcinoma.
      • IHC stains: CK (+).
    • 2020-12-28 patho - breast biopsy (no margin)
      • invasive carcinoma, no special type.
      • IHC stains: ER (+, strong intensity, 95%), PR(-), Her2/neu: negative (score=0), Ki-67(<2%).
  • consultation
    • 2021-01-18 Rehabilitation
      • Imp
        • Right breast invasive carcinoma with axillary metastasis
        • Lymphoma 30+ yrs ago
        • T-colon cancer found in 2020/12
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications
  • surgical operations
    • 2021-08-02 surgical operation
      • local excision abdominal wall tumor + small bowel resection with anastomosis
    • 2021-01-19 surgical operation
      • right breast MRM (modified radical mastectomy)
      • SILS (single incision laparoscopic surgery) left hemicolectomy + laparoscopic adhesionolysis
  • radiotherapy
    • 2021-07-15 ~ -07-30
      • 2400cGy/12 fractions (6 MV photon) to rt chestwall and SCF lymph nodes
  • chemo regimen
    • 2022-03-18 ~ undergoing - FOLFOX
    • 2021-11-16 ~ 2022-03-02 - FOLFIRI
    • 2021-08-20, -11-03
      • 5-Fu (fluorouracil) + Covorin (leucovorin)
    • 2021-04-28, -05-19, -05-26
      • Nolbaxol (docetaxel)
    • 2021-02-02, -02-24, -03-17, -04-08
      • Lipo-Dox (liposome doxorubicin) + Endoxan (cyclophosphamide)

==========

2022-04-27

  • The patient admitted to receive FOLFOX treatment, the current regimen being used since 2022-03-18.
  • No images have been updated since last hospitalization. The lab data reported on 2022-04-25 showed slightly elevated levels of BUN (43 mg/dL), creatinine (1.32 mg/dL), bilirubin total (1.26 mg/dL) and decreased level of potassium (3.2 mmol/L); these results should not affect the chemotherapy procedure.
  • TPR 36/106/17, BP 105/59 recorded at 19:50 2022-04-26. Insufficient blood pressure caused a faster pulse?
  • Drugs prescribed in the OPD have been put as self-carried items in the list of active medications.

2022-04-12

  • A patient with synchronous double primary cancers s/p surgery; systemic therapy was initially focused on breast cancer from 2021-02 to 2021-05, and then refocused on colon cancer from 2021-08 based on clinical judgment.
  • The CEA and CA199 levels have been trending upward from 43ng/mL and 59U/mL (2021-12-13) to 130ng/mL and 83U/mL (2022-04-07) respectively. Abdominal CT on 2022-03-16 showed progression of liver mets and possible peritoneal seeding.
  • As a result of the disease being resistant to FOLFIRI, the regimen has switched to FOLFOX since 2022-03-18.
  • Sundowning-like behaviors were observed during last hospital stay (2022-03-12 ~ 2022-03-31). According to nursing notes, these behaviors did not occur since this admission.
  • Lab data reported on 2022-04-06 showed normal liver and kidney function and no obvious abnormalities with CBC and WBC readings.

2022-03-15

  • Lab data reported on 2022-03-15 showed stool OB 3+, stool glutamate dehydrogenase (GDH) positive, Clostridium difficile toxin A/B negative.
  • Colonization with nontoxinogenic strains also affords protection. This observation suggests that the initial colonizing strain may occupy a microbial niche in the large intestine that is protective against superinfection with a new toxin-producing C. difficile strain
  • The antibiotics most frequently implicated in predisposition to C. difficile infection (CDI) include fluoroquinolones, clindamycin, penicillins, and cephalosporins.

2022-02-25

  • no updated exam findings as of last hospitalization (2022-02-10).
  • new lab data showed lower serum potassium 3.2mmol/L (reported on 2022-02-22) is treated with 0.298% KCl in NaCl 500mL IVD QD.
  • neutrophil is just above 1500/uL (WBC 2910/uL, Neutrophil 58%, 2022-02-22) should be regularly monitored.

2022-02-10

  • synchronous double primary cancers s/p surgical operation
    • systemic therapy had been focused on breast cancer from 2021-02 to 2021-05, then refocused on colon cancer since 2021-08 based on clinical judgement.
    • time serial CEA readings trend up slowly from 2021-07-27 25.48ng/mL to 2022-02-07 66.56ng/mL during last half year.
    • newly found liver tumor could be another metastatic lesion.
  • drugs approved by FDA for both breast cancer and colon cancer include: 5-FU, capecitabine, pembrolizumab.
    • polyp patho showed pMMR, pembrolizumab might not be indicated.
    • bevacizumab might be considered if no contraindication.
  • EGFR overexpression (up-regulation or amplification) or mutation is usually associated with progression and resistance of epithelial tumors.
    • reference: Wang Z. ErbB receptors and cancer. Methods Mol Biol. (2017)1652:3-35. doi:10.1007/978-1-4939-7219-7_1
    • cetuximab or panitumumab might be considered if no contraindication.
  • liver and kidney functions showed no abnormality based on ALT, AST, and creatinine reported on 2022-02-07.
    • introduction of irinotecan should not likely to be restricted.
  • no drug allergy recorded in database, no issue found in current medication.

2021-09-08

  • synchronous double primary cancers s/p surgical operation
    • systemic therapy had been focused on breast cancer from 2021-02 to 2021-05, refocused on colon cancer since 2021-08 based on clinical judgement.
  • drugs approved by FDA for both breast cancer and colon cancer include: 5-FU, capecitabine, pembrolizumab.
    • polyp patho showed pMMR, pembrolizumab might not be indicated.
  • liver and kidney functions showed no obvious abnormality based on ALT, AST, and creatinine reported on 2021-09-02.
    • introduction of irinotecan should not likely to be restricted because of hepatic dysfunction.

700529746

220426

  • 2022-04-25 Chest PA/AP view
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • S/P coronary artery stent implantation.
    • Spondylosis of the T-spine
    • Compression fracture of L1 vertebral body S/P cement vertebroplasty.
  • 2022-04-22 Chest PA/AP view
    • S/P operation.
    • S/P Port-A infusion catheter insertion.
    • S/P VP.
    • Patch density at bil. lungs.
  • 2022-04-18 MRI - upper abdomen
    • S/P operation.
    • Multiple LNs, lung and liver metastases.
    • Bil. pleural effusion.
  • 2022-04-18 Chest PA + Lat. LT
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • S/P coronary artery stent implantation.
    • Spondylosis of the T-spine
    • Compression fracture of L1 vertebral body S/P cement vertebroplasty.
  • 2022-04-01 Tc-99m MDP whole body bone scan
    • Increased activity in the lower C-spine, lower T- and upper L-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in the right shoulder, bilateral hips and right knee, compatible with benign joint lesions.
  • 2022-03-31 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated, consistent with metastatic colonic origin
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma and proliferating along the alveolar wall with focal tumor necrosis.
    • The immunohistochemical stains reveal TTF-1(-) and CDX2(+). The results are consistent with metastatic colonic adenocarcinoma. Please correlate with the clinical presentation and image study.
  • 2022-03-31 Chest PA/AP view
    • no pneumothorax s/p transthoracic needle biopsy of RML nodule.
  • 2022-03-31 Whole body PET scan
    • Multiple glucose hypermetabolic lesions in bilateral lungs. Multiple lung metastases should be considered first. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Some glucose hypermetabolic lesions in the right and left lobes of the liver. Liver metastases should be watched out.
    • Glucose hypermetabolism in bilateral pulmonary hilar and multiple mediastinal lymph nodes and in multiple abdominal lymph nodes, compatible with metastatic lymph nodes.
    • Prominent glucose hypermetabolism in a focal area in the right lobe of the thyroid gland. The nature is to be determined (thyroid malignancy? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in a focal area in the right parotid gland and in a focal area in the left parotid gland. The nature is to be determined (some kind of parotid lesions? metastases? other nature).
    • Mild glucose hypermetabolism in some left lower neck lymph nodes and glucose hypermetabolism in the left shoulder. Inflammation is more likely.
  • 2022-03-31 MRI - brain
    • General brain atrophy. An old infarct in right corona radiata.
    • No evidence of brain metastases based on this non-contrast MRI.
  • 2022-03-21 CT - lung/mediastinum/pleura
    • multiple nodules in both lungs, favors metastatic tumors
    • suspect combined lung edema, pleural effusion, and LAD and LVD of heart. extensive 3V-CAD.
  • 2022-03-17 Chest PA erect view
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • S/P internal fixation of C-spine.
  • 2021-11-01 Chest PA erect view
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • S/P coronary artery stent implantation.
    • Spondylosis of the T-spine
    • Compression fracture of L1 vertebral body S/P cement vertebroplasty.
  • 2021-10-27 Patho - colorectal polyp
    • Colon, anastomotic site, s/p biopsy.(A) — Tubular adenoma with low grade dysplasia
    • Colon, T-colon, s/p biopsy.(B) — Hyperplastic polyp
    • Colon, D-colon, s/p biopsy.(C) — Hyperplastic polyp
    • Colon, S-colon, 20 cm from AV, s/p hot snare polypectomy and S-colon, 18 cm from AV, s/p cold snare polypectomy (D) — Tubulovillous adenomas with low grade dysplasia.
  • 2020-11-20 Myocardial perfusion SPECT with persantin
    • Probably moderate myocardial ischemia with possible a small portion of severe ischemia at the apex and anterior wall and mild to moderate myocardial ischemia at the anterolateral wall.
    • Mild reverse redistribution of radioactivity to the basal inferolateral wall, either normal variant or myocardial ischemia may show this picture.
  • 2020-09-26 MRA - brain
    • Moderate stenosis in the bilateral cavernous ICAs, esp, left side. Please correlate with cerebral angiography.
  • 2020-06-03 Patho - colon segmental resection for tumor
    • Pathologic diagnosis
      • Large intestine, hepatic flexure colon, SILS right hemicolectomy — Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection — metastatic adenocarcinoma (7/16)
      • Lymph node, IMA / SMA, dissection — N/A.
      • Pathology stage: pT3N2b(If cM0); pStage IIIC
    • Microscopic examination
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: pericolorectal tissue
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved
      • Lymph node metastasis, mesocolic: Positive (7/ 16)
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT) pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN) pN2b: Seven or more regional lymph nodes are positive
        • Distant Metastasis (pM) pMX
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A.
      • Tumor regression grading S/P CCRT: N/A.
  • 2020-06-02 CT - abdomen, pelvis
    • Imaging stage: T3N2M0, stage IIIB
  • 2020-06-02 Patho - colon biopsy
    • Colon, hepatic flexure, biopsy — Adenocarcinoma.
    • IHC stains: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2020-06-02 Patho - colorectal polyp
    • Colon, transverse, polypectomy — Tubular adenoma with low grade dysplasia
  • 2020-02-07 Paho - intradermal nevus
    • Skin, excision biopsy — Basal cell carcinoma, solid type, 0.1 cm away from the closest (side and deep) margin.
    • IHC stains: adipophilic(-), EMA(-), Ber-EP4(+).
  • 2019-11-04 MRA - brain
    • Diffuse arteriosclerosis with multi-focal stenoses.
    • Brain atrophy.
  • 2019-04-17 CPA - carotid phonoangiograph
    • Sonographic diagnosis
      • Multi-focal mild stenosis in bil BIF, bil ICA, right ECA; mild atheromatous lesions in right SCA, right CCA.
      • Normal extracranial carotid, vertebral, and right intracranial basal cerebral arterial flows; severe stenotic flow in right ICA, bil ECA, left SCA; mild to moderate stenotic flow in right PCA and right ECA.
      • Poor temporal windows for left transcranial insonation.
      • Normal bilateral ophthalmic arterial flows.
      • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • 2018-12-21 KUB
    • Osteoporosis, mild scoliosis and spondylosis of L-spine. S/P VP at T12. S/P TPS and disc prosthesis at L3-4-5. Mottled bowel gas pattern.
  • 2018-10-17 CPA - carotid phonoangiograph
    • Sonographic diagnosis
      • Severe stenosis with severe stenotic flow in right proximal ICA; moderate to severe stenosis with mildly increased flow velocity in left proximal ECA; moderate stenosis in right distal CCA and right BIF; multi-focal mild stenosis in right proximal & mid CCA, left distal CCA, left BIF and left proximal ICA; moderate atheromatous lesions in left mid CCA.
      • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows; severe stenotic flow in right proximal ICA and BA; mild stenotic flow in left ECA and right intracranial VA; smaller caliber and decreased flow in right cervical VA, indicated hypoplasia.
      • Poor temporal windows for bilateral transcranial insonation.
      • Normal bilateral ophthalmic arterial flows.
      • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • 2018-09-03 CT - brain
    • No brain lesion.
    • Intracranial ICAs and VAs atherosclerosis.
    • Age-appropriate cerebral atrophy.
  • 2018-06-27 Upper GI panendoscopy
    • Erosive esophagitis (La Gr A-)   - Hiatal hernia
  • 2018-06-20 Myocardial perfusion SPECT with persantin
    • Probably (1) moderate myocardial ischemia in the apex and anterior wall (LAD territory) and (2) mild myocardial ischemia in the basal lateral wall (LCx-M territory) of the left ventricle.
    • No post-stress dilatation of the left ventricle.
  • 2017-03-24 Upper GI panendoscopy
    • gastric shallow ulcers and erosions, antrum
  • consultation
    • 2021-10-21 Gastroenterology
      • PI
        • ADHF, with pulmonary edema, s/p ETT+MV 10/08-10/14
      • S
        • still tarry stool today
      • O
        • E4V5M6
        • Hb: 11.7->8.6->9.2
        • EGD: no active bleeder
      • A
        • Black with dark green stool, suspected LGIB
      • P
        • Arrange colonscopy on 10/23 AM if the patient and family understand the risk of CFS (organ perforation… etc)
        • Add transamine
    • 2021-10-18 Rehabilitation
      • Q
        • For CHF of cardiopulmonary muscle endurance training and muscle strengthening exercise.
        • 2021/10/08 heart echo showed: EF = 21.1%; Dilated LA; Poor LV systolic function, generalized hypokinesis, especiaaly IVS; Concentric LV hypertrophy, Impaired LV relaxation; Moderate MR.
        • This 76 year old female had a past history of
          • NSTEMI, s/p stent placement at ShuangHo Hospital 202109 under Bokey + Blingta
          • 3-V-D s/p PTCA and Rota, 2 stents over RCA on 20161019
          • Pneumonia
          • Chronic kidney disease stage 4
          • Hypertension
          • T2DM control with Humalog Mix25 38u BID
          • Anemia, gastric OB 3+, UGIB cannot be ruled out
          • Colon Ca, pT3N2bM0, stage IIIC s/p laparoscopic right colectomy on 20200603
          • C4-5-6-7 HIVD s/p op in 201310 and L3-4-5 s/p op in 20130529.
          • PUD hx
        • According to her husband, she experienced dyspnea for last weeks. The symptoms persisted and progressed despite of OPD follow up. Thus she came to our ED for help. At ER, CXR revealed bilateral pulomonary inflitration, suggesting acute pulmonary edema. Breathing pattern was swallow and fast. Intubation was performed after informed consent. Under the impression of acute decompensated heart failure with pulmonary edema, she was admitted into ICU for further medical care. After admitted to MICU, 2D echo was done and showed Dilated LA, Poor LV systolic function, generalized hypokinesis, especiaaly IVS, Concentric LV hypertrophy, Impaired LV relaxation, Moderate MR. EF was 21% under Simpson method. Lasix 40mg Q12H was given and much urine output and BW loss were noted. Empirical Abx with rocephine was also prescribed since 20211008. Mexiletine and Ivabradine was given. Due to no active bleeding sign, oral diet was resumed and PPI was shifted to oral. However, acute on CKD was noted on 20211012, suspected pre-renal AKI. Lasix was tapered off, minimal IV hydration with 500cc NS QD was given. The ventilator was tapered smoothly. T-piece was tried on 20211013. On 20211014, extubation was done and BIPAP support was given. The patient weaning off BIPAP soon after 1 day. She also tolerated oral diet well. F/u CXR and lab were both improved with residual left consolidation. No fever was noted thus Ceftriaxone was discontinued after 1 wk. Under stable condtion, she was transfered to ward on 20211018.
      • A
        • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
        • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
    • 2021-10-08 Cardiology
      • BILATERAL pulmonary edema noted s/p intuvbation. With her creatine 3.2, no obvious progression compared her last creatinine study.
      • Received cath at nearby hostpital for LAD. No obvious lower limb swelling this time.
      • Last echoc was performd at 202012 with preserved LV function, thus, the pulmonary edema cause would multi-factorial, pending on admission to MICU by ER doctor.
    • 2020-12-16 Nephrology
      • Q
        • Reason: for CKD stage 4 assessment
        • This is a 75 years old lady who has CAD s/p stent, DM for 20+ years, Ca colon s/p op in June 2020.
        • Patient was admitted for planned CAG on 20191216, However, we noted patient had renal anemia, (Hb : 8.6 with eGFR < 15) (Stool OB: negative Oct 2020). currently using plavix, progressive renal function impairment.
        • We arranged Ca,P, iPTH, Iron profile, Ferritin, renal echo, urine analysis and proteinuria screening
        • WE consult you for assessment of EPO SC usage and CKD managment with your superior profession.
      • A
        • Impression
          • CKD stage 4, suspect DM nepropathy relatd
          • CAD s/p stent
          • DM
          • Ca colon s/p op on June 2020.
        • Suggestion
          • Stage 4 cannot use EPO
          • Nephrology OPD follow up was suggested
          • Treat the underlying diseases as your expertise
          • Avoid nephrotoxc agents
  • surgical operation
    • 2020-06-03 SILS right hemicolectomy 
    • 2020-02-07 skin excision
      • a flesh color papule with hyperpigmented dots on nose for years -> suspected BCC
  • chemoimmunotherapy
    • 2022-04-25 ~ undergoing - FOLFIRI

[assessment]

  • This DM related CKD stage 4 patient has advanced colon cancer with lung mets s/p left hemicolectomy on 2020-06-03. She has been receiving FOLFIRI as from this hospitalization.
  • Lab data on 2022-04-25 showed BUN 70mg/dL, urine creatinine 3.95mg/dL, eGFR 11.71, HGB 9.0 g/dL, serum uric acid 8.8 mg/dL. Hyperuricemia is managed with Feburic (febuxostat) 40mg PO QD currently.
  • There are no irinotecan dosage adjustments provided in the manufacturer’s labeling (has not been studied) for kidney impairment, please use with caution and monitor closely. Use of irinotecan in patients with dialysis is not recommended by the manufacturer; however, literature suggests reducing weekly dose from 125 mg/m2 to 50 mg/m2 and administer after hemodialysis or on nondialysis days. Irinotecan is associated with early and late diarrhea, both of which may be severe (atropine has been subscribed as a pre-/co-treatment in the regimen). In the event the patient develops diarrhea, supportive care (e.g. fluid and electrolyte replacement, loperamide, antibiotics, etc.) should be provided as needed.
  • The patient has two stents for her coronary artery disease. Cardiotoxicity observed with 5-FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of 5-FU administration following development of cardiac toxicity, and the drug should be discontinued. She is also taking Plavix (clopidogrel) for her stents, for bevacizumab has the potential to cause hypertension, hemorrhage, and thromboembolism, so the patient should be closely monitored if bevacizumab is also administered.
  • Erythropoietin 5000U weekly could be considered as an additional item if no contraindiction, until the reading backs to 11 g/dL.

700886156

220425

[objective]

  • exam finding
    • 2022-04-02 ECG
      • Atrial fibrillation with rapid ventricular response
      • ST & T wave abnormality, consider lateral ischemia
    • 2022-03-30 CT - lung/mediastinum/pleura
      • recurrent esophageal cancer with spinal metastasis, in progresion.
      • post op change in RML and RUL.
      • small amount of pleural effusion, exudative, in regression.
      • dendritic change or old fibrosis at LLL and lingula
    • 2021-12-23 Chest PA erect view
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Pleura effusion of right and left costal-phrenic angle
      • S/P posterior instrumentation fixation at T-spine
    • 2021-12-22 SONO - chest
      • Pleural effusion, moderate, left
      • Atelectasis, RML, RLL and RUL
    • 2021-12-15 CT
      • Hemangioma or Metastasis 1.1 cm in S2/4 is highly suspected.
    • 2021-10-29 Patho - Interveterbral disc
      • T6 pathologic fx
      • Bone and joint, vertebra, T6 body, corpectomy - Neuroendocrine carcinoma.
      • IHC: CK (+, intermediate intensity), S-100 protein (+), CK7 (-), CK20 (-), CD117 (-), CD56 (+, intermediate intensity), p40 (-), TTF-1 (-). Ki-67: 20%.
    • 2021-10-23 MRI - T-spine
      • T5-6-7 metastases with thecal sac and spinal cord compression.
    • 2021-10-19 CT
      • recurrent esophageal cancer with spinal metastasis.
      • post op change in RML and RUL.
      • small amount of pleural effusion, exudative, in progression, and nonspecific inflammation or fibrosis in left lower lung, stationary.
    • 2021-04-20 CT
      • post op change in RML and RUL.
      • small amount of Rt pleura, exudative, post op change? and nonspecific inflammation or fibrosis in left lower lung, stationary.
    • 2021-01-19 CT
      • post op change in RML and RUL.
      • small amount of Rt pleura, exudative, post op change? and nonspecific inflammation or fibrosis in left lower lung.
    • 2020-09-29 Patho - Lung wedge biopsy
      • Lung, RML, VATS pneumolysis+ RML wedge - necrotizing granuloma
      • IHC: CK7(-), TTF-1(+ at pneumocytes), Ki-67: <10%.
    • 2020-09-28 Frozen section
      • Lung, RML, frozen section - Necrosis with focal atypia (reactive change or AAH?)
    • 2020-09-03 CT
      • s/p esophagectomy with gastric tube reconstruction.
      • Tiny nodular lesion at right middle lobe, suspected lung meta.
    • 2020-06-02 CT
      • new RML nodules, favor metastatic lesions.
      • residual small amount of Rt pleura and nonspecific inflammation in left lower lung.
    • 2019-07-09 CT
      • Pleura effusion, stationary and increased volume of pericardial effusion.
      • post op change in RLL and nonspecific inflammation in left lower lung, stationary.
      • No abnormal soft-tissue mass or LAP in the mediastinum.
    • 2018-03-29 Whole body PET scan
      • In comparison with the previous study on 2017-04-17, the glucose hypermetabolic lesion between the descending aorta and the thoracic spine is more prominent. Recurrent malignancy should be considered.
      • Glucose hypermetabolism in the right supraclavicular fossa. The nature is to be determined (metastatic lesion? other nature?).
      • Glucose hypermetabolism in both lobes of the thyroid gland and left cricoarytenoid area. The nature is to be determined (inflammation? other nature?).
    • 2017-03-27 Surgical pathology Level V
      • Lung, RLL, wedge resection - Squamous cell carcinoma x 3, poorly differentiate (G3), metastatic
      • IHC:
        • the large tumor reveal CK5/6(+), p40(weak +), p63(+), and TTF-1(-).
        • the 2 small tumors reveal p40(+), CD56(-), and TTF-1(-).
    • 2017-03-15 CT
      • Indication: Esophageal cancer, M/3, squamous cell carcinoma, cT2N2M0, with Rt paratracheal and subcarinal LAP metastasis, Rt vocal cord paralysis, s/p PortA on 2016-01-15, s/p CCRT since 2016-01-21 to 2016-03-03 s/p esophagectomy & LN dissection on 2016-04-23, ypT3N0 (cM0) with involved circumferential (adventitial) margin s/p fistulectomy on 2016-06-17.
      • s/p esophagectomy and gastric tube reconstruction.
      • A RLL nodule, recurrent tumor in lung?
      • Inflammation in LLL-basal segments.
  • surgical operation
    • 2021-10-28
      • Surgery
        • Esophagal cancer with T5-6-7 spinal metastasis; tumor excision and ant/ post fixation; Modified LECA approach
      • Finding
        • Esophageal tumor s/p previous op.
        • T5-6-7 metastastic tumor with T6 pathologic fracture/ epidural circumferential cord compression, more at anterolateral area;
        • Circumferential epidural tumor 3x3x3cm caused severe cord compression;
    • 2020-09-28
      • Surgery
        • VATS pneumolysis + RML wedge
      • Finding
        • severe intra-pleura cavity adhesion due to previous RLL wedge for esophagus SCC metastasis
        • one nodule about 1cm with caseating granuloma and calcification was found in RML
        • Estimated blood loss: 150mL.
        • one 20 Fr. straight chest tubes were inserted via right 7th ICS. 
    • 2019-07-29
      • Diagnosis
        • Pericardial effusion
      • PCS code
        • 68049B
      • Finding
        • Moderate serosangious pericardial effusion was noted about 300mL.
        • One 14 Fr. pig-tail was inserted via left 7th ICS.
    • 2017-03-27
      • Diagnosis
        • RLL lung nodule
      • PCS code
        • 67051B
      • Finding
        • One firm nodular lesion was noted over RLL, size about 1.5cm in diameter.
        • One 28 Fr. straight chest tube was inserted via right 8th ICS.
  • radiotherapy
    • 2018-04-12 ~ 2018-05-07: 4500cGy/18 fractions (15 MV photon) to para-T6 tumor (part of CCRT)
  • chemotherapy
    • 2022-04-22 - PFL (cisplatin + 5-Fu + leucovorin)
    • 2021-12-16 ~ 2022-03-29 - cisplatin + etoposide
  • consultation
    • 2021-12-21 Thoracic Medicine
      • Q
        • This 74-yrear-old man patient is a case of Esophageal cancer, M/3, squamous cell carcinoma, cT2N2M0, with Rt paratracheal and subcarinal LAP metastasis, Rt vocal cord paralysis, s/p PortA on 20160115, s/p CCRT since 20160121 to 20160303 s/p esophagectomy & LN dissection on 20160423, ypT3N0 (cM0) with involved circumferential (adventitial) margin s/p fistulectomy on 20160621 with lung metastasis s/p resection on 201703 s/p adjuvant C/T, last on 20180108 with 2nd mediastinum relapse in 201803 s/p salvage RT on 20180507.
        • Pericardial effusion s/p Thoracoscopic Pericardial Window and Pneumonolysis, extrapleural.
      • A
        • I was consulted wheezing and suspected COPD of the patient
        • objective
          • PFT in 2017: normal screening, no further data
          • CXR cardiomegaly and left PE
          • Fibroreticular infiltration in right lung field
          • Mediastinum widening
          • Diffuse pleural thickening was found bilaterally, especially on right
        • assessment
          • recurrent esophageal ca with multiple mets
          • suspected COPD
          • restrictive lung ventilatory defect was suspected for bilateral irregularly thickened pleurae
        • plan
          • keep current bronchodilator nebulization
          • inform high risk of acute respiratory failure, plan of further tx?
          • sputum AFS/TB cultures x 3 days
          • chest echo for left pleural effusion if dyspnea
    • 2021-11-03 ENT
      • Q: Current problem:
        • Tinnitus since 2021-10-29.
        • Post-op wound suspected CSF leakage. Remove drain on 2021-10-30.
        • We will give AcetaZOLAMAX 250 mg/tab (AcetaZOLAMIDE) and Diphenidol S.C 25mg/tab use.
        • We need your expertise for further management.
      • A
        • L>R pulsatile tinnitus for 3 days.
        • PE:
          • Ear drum: bil intact, L ear drum atrophic scar
          • EAC: clean
          • Bedside scope: smooth NPx, OPx, HPx
        • Tymp:
          • R’t type A; L’t type A with round peak.
        • ART: Bil absent.
        • PTA:
          • Average RE 49 dB HL; LE 79 dB HL.
          • R’t normal to severe SNHL.
          • L’t moderately severe to profound mixed type HL.
        • Suggestion:
          • keep current Betahistine 1# BID
          • ENT OPD follow up for PTA and hearing aid evaluation
    • 2021-11-01 Rehabilitation
      • Q
        • This 73-year-old patient has past history of
            1. Coronary artery disease,
            1. Hypertension,
            1. Enlarged prostate with lower urinary tract symptoms,
            1. Gout,
            1. Middle third esophageal squamous cell carcinoma with lung metastasis pathology stage: Stage IV, pT3N0M1 s/p CCRT,
            1. Hypothyroidism,
            1. AF,
            1. Hyperlipidemia,
            1. Right middle lobe lung nodule status post-video-assisted thoracic surgery pneumolysin and right middle lung wedge resection on 2020-09-28.
        • He was a regular follow-up at our OPD. This time, he suffered from left leg clumsiness and weakness for two weeks. Mild lower chest pain. He was being referred from Oncology OPD. T-spine MRI with/without contrast showed T5-6-7 metastases with thecal sac and spinal cord compression. After discussing with the patient and his family surgical risk. He was admitted for surgical intervention. Esophagal cancer with T5-6-7 spinal metastasis post tumor excision and posterior fixation on 20211028. Post-operative course was uneventful. His discomfort was relieved a lot.
        • Current problem:
          • Chest pain improve.
          • He complaint still left leg clumsiness and weakness.
          • Muscle power: Upper limbs: Rt 5 Lt 5; Lower limbs: Rt 5 Lt 4-5
          • Gait: unstable gait. Need use a walker to walk.
        • We need your expertise for physical therapy.
      • A
        • MP:
          • upper limbs 5/5
          • lower limbs
          • Quadriceps R/L 5/4
          • Knee extensors R/L 5/4
          • Ankle dorsiflexors R/L 4/4
          • Ankle plantar flexors R/L 4/4
          • toe extensors 4/4
          • BADL: max A
          • ambulation: now walker with min A
        • Plan
          • Rehabilitation programs: GYM PT + OT rehabilitation programs
          • Goal: recondition, improve endurance and muscle strength

==========

2022-04-25

  • After receiving etoposide + cisplatin since December 2021, the patient’s chemotherapy regimen has been changed to 5-FU + cisplatin since this hospitalization following 2022-03-30 CT evidence of progression. The new regimen is generally tolerated by the patient.
  • A variety of underlying diseases such as coronary artery disease, hypertension, enlarged prostate, lower urinary tract symptoms, gout, hypothyroidism, AF, and hyperlipidemia are currently treated with appropriate medications.
  • Lab data on 2022-04-20, liver and kidney functions, serum electrolytes and blood cell counts were grossly normal, except decreased WBC level of 2780/uL (neutrophil 58%) which should be noted.

2022-03-30

  • No updated images for this patient since last hospital stay. Lab data reported on 2022-03-29 indicated that the CBC readings were below normal ranges and CEA (6.02 ng/mL), SCC (1.7 ng/mL) were above normal ranges.
  • EP (etoposide + cisplatin) has been administered since December 2021 for his neuroendocrine carcinoma, and the patient has no intolerance during this hospitalization according to nursing note.
  • Pembrolizumab can be considered for patients with dMMR/MSI-H or advanced tumor mutational burdenhigh (TMB-H) tumors that have progressed following prior treatment and have no satisfactory alternative treatment options.
  • In the event hypothyroidism remains a diagnosis (no updated lab data found since 2022), then levothyroxine (Eltroxin) might be considered.

2022-03-02

  • EP (etoposide + cisplatin) is applied since Dec 2021 and the patient tolerates the treatment during this hospitalization.
  • if somatostatin receptor (SSR) is proved positive, then octreotide or lanreotide might be an optional add-on.

700973989

220422

{esophageal squamous cell carcinoma with liver and lung mets}

[objective]

  • exam finding
    • 2022-04-20 SONO - chest
      • left side moderate hemothroax, s/p chest tapping 600 ml bloody effusion for study and s/s relief
      • right side moderate pleural effusion, s/p chest tapping 350 ml for study
    • 2022-04-13 Chest PA (erect) view
      • A poorly defined huge mass over over medial RUL and midlung zone with multiple nodular opacities in both lungs, due to metastases
      • Bilateral pleural effusions
      • Superior mediastinal widening due to lymph node enlargement,
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
    • 2022-04-11 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, some T-and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, right femoral trochanters, and right knee.
    • 2022-04-08 Patho - lung transbronchial biopsy
      • Lung, right, CT-guide biopsy — squamous cell carcinoma, please correlate with the clinical presentation and image study to differentiate primary or metastatic tumor
      • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma. Focal keratinization is seen.
      • The immunohistochemical stains reveal p40(+), and TTF-1(-). Please correlate with the clinical presentation and image study to differentiate primary or metastatic tumor.
    • 2022-04-07 MRI - brain
      • No obvious intracranial lesion.
      • Large patchy area of encephalomalacia over left PCA territory.
      • Also small areas of old infarction over right frontal lobe, right medial occipital lobe, bilateral cerebellar lobe.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • 2022-04-06 Cell block
      • Suggestive of malignancy
      • The smears and cell block show lymphocytes, reactive mesothelial cells and a few atypical cell nests, which immunocytochemistry shows TTF-1(-), Napsin-A(-) and P40(+, scant) for atypical cells, suggestive of malignancy. According to cytomorphologic finding, it is compatible with metastatic squamous cell carcinoma. Please refer to S2022-05907 and clinical correlation for tumor origin.
    • 2022-04-02 CT - chest
      • Imaging stage: T4aN3M1, stage IVB
    • 2022-04-01 Pathology - esophageal biopsy
      • Esophageal tumor, 27 and 40 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
      • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by solid tumor nests with enlarged, hyperchromatic and pleomorphic nuclei infiltratde in the stroma with focal keratin formation and some necrotic debris.
    • 2022-03-31 Esophagogastroduodenoscopy, EGD
      • Reflux esophagitis LA A
      • Highly suspected esophageal cancer, 27-40cm, s/p biopsy
      • Superficial gastritis
  • consultation
    • 2022-04-21 family medicine
      • Q:
        • The 66-year-old male has history of Type II Diabetes mellitus and Hypertension under Chang Gung OPD follow up and esophageal cancer with lung and liver meta. He suffer from short of breath for one day. He came to our ER for help on 20220402. Under the impression of esphogeal cancer, jejunostomy performed on 20220414 and intubated ETT at the same day. The patient prefer palliative care, so extubated on 20220418. However, tachypnea with short of breath were noted, NIPPV supportive.
        • Current problem: We need Hospice care and take over the patient for palliative care.
      • A:
        • 66y/o gentleman just dx advanced esophageal cancer
        • Dyspnea s/p intubation now with BIPAP
        • DNR +
        • ECOG 4
        • Would put p’t on Hospice ward list.
        • Our share care would follow up.
    • 2022-04-20 Thoracic Medicine
      • Q:
        • The 66-year-old male has history of Type II Diabetes mellitus and Hypertension under Chang Gung OPD follow up and esophageal cancer with lung and liver meta. He suffer from short of breath for one day. He came to our ER for help on 20220402. Under the impression of esphogeal cancer, jejunostomy performed on 20220414 and intubated ETT at the same day. The patient prefer palliative care, so extubated on 20220418. However, tachypnea with short of breath were noted, NIPPV supportive.
        • Current problem: We need your specialist to arrange pleural drainage.
      • A:
        • A case of heavy smoking with COPD, admitted due to esophageal cancer s/p palliative feeding jejunostomy.
        • Bed-side chest echo had been done and showed right side serosanguous exudative PE and left side hemothorax, s/p chest tapping with left side 350ml and right side 600ml.
        • Suggestion:
          • Left side chest tube drainage for hemothorax.
          • Add foster 2puff BID, spiriva 2puff HS.
          • F/U prn.
    • 2022-04-18 Infectious Disease
      • Q:
        • Esophgeal Ca with lung metastasis s/p Feeding jejunostomy
        • Developed high fever suspected pneumonia
      • A:
        • Antibiotic therapy should be adjusted according to the results of in vitro sensitivity testing.
        • NO treatment for colonization. Do NOT use steroid.
    • 2022-04-09 Hemato-Oncology
      • Impression:
        • Esophageal cancer with liver and lung metastasis
        • Type II Diabetes mellitus
        • Hypertension
        • Old CVA
      • Suggestion:
        • We will discuss with patient about further treatment after complete work up
        • Please check AntiHbc, SCC
        • May consult chest surgeon for port A insertion and involve in this case.
        • Consult GI to involve in this case (esophagus stent? or gastrostomy?)
        • Consult RT for CCRT
    • 2022-04-06 Radiological Diagnosis
      • Q: for chest CT guiding biopsy of lung mass, sinecrely need your professional evaluation
      • Q:
        • This 66-year-old patient is a case of bilateral lung nodules, suspected metastasis or primary lung cancer.
        • CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.

[assessment]

  • This patient, who suffers from esophageal squamous cell carcinoma with liver and lung metastases, has been placed on the hospice waiting list on 2022-04-21.

701198481

220422

[objective]

  • exam finding
    • 2022-04-01 Abdomen - Standing(Diaphragm)
      • Fecal material store in the colon.
      • Ascites is suspected. Please correlate with sonography.
    • 2022-03-22 Abdomen - Standing(Diaphragm)
      • Air-fluid level in the bowel at the upper abdomen is noted that may be bowel obstruction? Please correlate with contrast enhanced CT.
      • Fecal material store in the colon.
      • Ascites is suspected.
    • 2022-03-09 Abdomen - Standing(Diaphragm)
      • Fecal material store in the colon.
      • Ascites is suspected. Please correlate with sonography.
    • 2022-03-07 Abdomen - Standing(Diaphragm)
      • Multiple segment of small intestine show air-fluid level that are c/w bowel obstruction.
      • Ascites is suspected. Please correlate with sonography.
    • 2022-03-04 CT - abdomen, pelvis
      • Carcinomatosis induce mechanical bowel obstruction is suspected.
    • 2022-03-04 KUB
      • Increased intestinal gas is found.
      • Stool impaction at the abdominal cavity is noted.
    • 2021-11-23 CT - abdomen, pelvis
      • Stationary of pancreatic tail low density lesion.
      • More prominent soft tissue density in RLQ, suspected carcinomatosis.
      • Stationary of bilateral lung nodules, suspected lung metastasis.
    • 2021-11-09 Tc-99m MDP bone scan
      • In comparison with the previous study on 20210120, no prominent change is noted, suggesting no strong evidence of bone metastasis.
      • Suspected benign lesions in the maxilla, middle T-spines, lower L-spines, sacrum, bilateral sacroiliac joints, shoulders, sternoclavicular junctions, hips, and knees,
    • 2021-09-21 CT - abdomen, pelvis
      • Small bowel ileus, suspected adhesion.
      • Relative increased density in RLQ, suspected carcinomatosis.
      • Stationary of pancreatic lesion.
      • Left lower lung nodule, suspected lung metastasis.
    • 2021-07-13 Abdomen - Standing(Diaphragm)
      • Fecal material store in the colon.
    • 2021-07-12 CT - abdomen, pelvis
      • Stationar condition of pancreatic cancer and peritoneal carcinomatosis as compared with previous CT study on 20210511.
    • 2021-05-11 CT - abdomen, pelvis
      • Dilated pancreatic duct at tail portion. The pancreatic condition is stationary.
      • No evidence of mestastatic lesion in the study.
    • 2021-04-18 Abdomen - Standing(Diaphragm)
      • Fecal material store in the colon.
    • 2021-03-02 CT - abdomen, pelvis
      • Suspected rupture appendicitis.
      • Suspected abscess in the pelvic cavity.
    • 2021-01-20 Tc-99m MDP bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in middle T-spine, lower L-spine, sacrum, sacroiliac joints, shoulders, sternoclavicular junctions, hips, and knees.
    • 2021-01-19 CT - abdomen, pelvis
      • Non-visualization of the pancrreatic tumor. Either current therpay is effective or the diagnostic method should be further investigated.
    • 2020-12-14 Abdomen - Standing(Diaphragm)
      • Transitional vertebra of L5-S1, left side.
    • 2020-10-12 CT - abdomen, pelvis
      • Stationar condition of pancreatic cancer and peritoneal carcinomatosis as compared with previous CT study on 20200706.
    • 2020-07-20 Tc-99m MDP bone scan
      • Mildly and non-focally increased radiotracer uptake in middle T-spine, lower L-spine, and sacrum that had been less evident in comparison with the previous study on 20200204, degenerative spine diseases may show such a picture.
      • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, sacroiliac joints, hips, and knees.
      • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
    • 2020-07-06 CT - liver, spleen, biliary duct, pancreas
      • Much regression of pancreatic cancer and peritoneal carcinomatosis.
    • 2020-04-07 CT - abdomen, pelvis
      • Pancreatic malignancy s/p treatment.
      • Regression of peritoneal carcinomatosis.
    • 2020-02-04 Tc-99m MDP bone scan with SPECT
      • Increased activity in the lower C-spine and lower L-spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the bilateral shoulders, bilateral sternoclavicular junctions, hips, knees, ankles and both feet, compatible with benign joint lesion.
    • 2020-01-02 CT - abdomen
      • Pancreatic carcinoma imaging stage: T1cN1M1, Stage IV
      • Other findings: mild repression of primary tumor and peritoneal seeding
    • 2019-09 Pathology - omentum (at VGHTPE)
      • pancreatic adenocarcinoma, metastatic, cT4N1M1
      • CK7(+), CK20(-).
  • lab data
    • CEA
      • 2022-04-19 8.36 ng/mL
      • 2022-04-08 8.734
      • 2022-04-06 8.86
      • 2022-03-23 5.451
      • 2022-02-22 10.47
      • 2022-02-08 8.176
      • 2022-01-19 5.384
      • 2022-01-03 6.370
      • 2021-12-21 5.508
      • 2021-11-25 7.414
      • 2021-04-28 2.419
      • 2021-04-20 2.64
      • 2021-03-04 1.607
      • 2021-01-14 1.155
      • 2020-12-09 1.343
      • 2020-12-08 1.11
      • 2020-11-06 1.757
      • 2020-10-02 1.591
      • 2020-08-28 1.875
      • 2020-08-04 0.749
      • 2020-04-13 1.86
      • 2020-02-27 2.766
      • 2019-12-31 3.478
      • 2019-11-05 2.995
      • 2019-10-16 2.789
    • CA199
      • 2022-04-19 10566.2 U/mL
      • 2022-04-08 10638
      • 2022-04-06 5603.49
      • 2022-03-23 10346.6
      • 2022-02-22 9232.6
      • 2022-02-08 8534.6
      • 2022-01-19 8673.8
      • 2022-01-03 9546
      • 2021-12-21 8695.7
      • 2021-12-17 3930.36
      • 2021-12-03 11539.95
      • 2021-11-25 11030.5
      • 2021-11-09 16219.4
      • 2021-10-13 12661
      • 2021-09-17 5472.1
      • 2021-09-07 6671.4
      • 2021-08-06 3643.3
      • 2021-07-23 4275.3
      • 2021-07-09 2841.0
      • 2021-06-25 3306.2
      • 2021-06-18 3287.4
      • 2021-06-08 3073.35
      • 2021-05-25 3015.7
      • 2021-05-12 3141.6
      • 2021-04-28 2667.2
      • 2021-04-20 1630.65
      • 2021-04-01 1143.5
      • 2021-03-19 701.39
      • 2021-03-04 354.060
      • 2021-02-24 335.25
      • 2021-01-15 177.130
      • 2021-01-14 169.370
      • 2020-12-16 110.182
      • 2020-12-08 156.614
      • 2020-11-06 71.735
      • 2020-10-02 38.132
      • 2020-08-28 23.155
      • 2020-08-11 21.897
      • 2020-07-31 20.589
      • 2020-07-20 19.681
      • 2020-06-24 23.338
      • 2020-05-29 29.415
      • 2020-04-30 64.378
      • 2020-04-13 68.09
      • 2020-04-08 145.41
      • 2020-02-27 493.18
      • 2020-02-04 678.54
      • 2019-12-31 1127.2
      • 2019-12-03 1981.5
      • 2019-11-14 3700
      • 2019-11-05 4329.2
      • 2019-10-18 8888.3
  • chemoimmunotherapy
    • 2022-04-15 - gemcitabine
    • 2022-04-07 - carboplatin + gencitabine
    • 2021-09-29 ~ 2022-03-21 - FOLFIRI?
    • 2020-09-14 - FOLF (irinotecan to be plused)
    • 2020-02-13 - 2021-09-07 - gemcitabine + nal-paclitaxel
    • 2020-02-06 - gemcitabine
    • 2019-10-21 ~ 2020-01-20 - FOLFIRINOX (experienced oxaliplatin-allergic shock 2020-01)
    • 2019-10-07 - oxalip 150 mg iv q2wk plus TS-1 60 mg 3tab bid and folic acid 2tab bid

[assessment]

  • Initially diagnosed with pancreatic carcinoma (T1cN1M1, Stage IV) in September 2019, followed by FOLFIRINOX between 2019-10 and 2020-01; following oxaliplatin allergy, the regimen changed to gemcitabine + nal-paclitaxel until 2021-09; following lung metastases, the regimen changed to 5-Fu + irinotecan until 2022-03; following carcinomatosis-induced mechanical bowel obstruction, the regimen changed to carboplatin + gencitabine since 2022-04.
  • The patient experienced severe back pain on 2022-04-20 night and was taken to the Emergency Department. Morphine 5mg IVD PRNQ4H is prescribed to treat the pain.
  • Lab readings on 2022-04-21 were CRP 7.53mg/dL, urine bacteria 3+, urine OB 2+, urine sediment RBC 6-9/HPF, urine sediment WBC 50-99/HPF. Body temperature did not exceed 37.5 degrees during this hospital stay for now. The blood culture has been ordered, but the results are not yet available. Empirical antibiotics ceftriaxone 2000mg IVD QD are being used since 2022-04-22.
  • Vemlidy (tenofovir alafenamide) is used to treat underlying positive HBsAg.

            

700466967

220421

[objective]

  • exam finding
    • 2022-04-14 MRI - brain
      • A left posterior cerebellar tumor, consistent with metastasis.
    • 2022-04-14 CT - brain
      • One mass lesion (2.8cm in size) over left cerebellar lobe with perifocal edema. Compatible with a metastasis.
      • Mild dilatation of ventricles.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
    • 2022-04-14 Patho - lung transbronchial biopsy
      • Lung, right, CT-guide biopsy — consistent with metastatic choriocarcinoma
      • Section shows alveolar tissue with infiltration of large pleomorphic tumor cells and tumor necrosis.
      • The immunohistochemical stains reveal CK7(+), CK20(-), beta-hCG(+), GATA-3(+), TTF-1(-), OCT3(-), PLAP(-), and SALL4(equivocal). The results are consistent with metastatic choriocarcinoma. Please correlate with the clinical presentaiton and lab study.
    • 2022-04-12 CT - chest
      • bilateral lung metastatic tumors.
      • two hepatic hemangiomas up to 35 mm.
    • 2022-04-08 MRA - brain
      • Left cerebellar metastasis.
    • 2022-04-08 CT - brain
      • Probably left cerebellar metastasis.
    • 2021-12-20 Chest PA/AP view
      • a large consolidation with lobulated contour over Rt lower lobe, in regression as compared with previous chest image
      • near complete resolution of the LLL small nodule post transthoracic needle biopsy
    • 2021-12-14 Chest PA/AP view
    • diffuse consolidation in Rt lower lobe stationary as compared with previous chest image
    • a nodular opacity (well-defined) over LLL
    • 2021-12-14 Patho - lung transbronchial biopsy
      • Lung, LLL, CT-guide biopsy — Scant atypical cells present
      • Sections show alveolar lung tissue with interstitial fibrosis and scant atypical cells in fibrous stroma.
      • The immunohistochemical stains reveal CK(+), p40(-), TTF-1(-), Napsin A(-), CD56(-), SALL4(-), and OCT4(-). Please correlate with the clinical presentation and lab study. Further examination is suggested.
    • 2021-12-07 SONO - chest
      • lung consolidation, suspected abscess
    • 2021-12-06 Chest PA (erect) view
      • Radiopacity in right middle and lower lung zone, suspected mass or loculated pleural lesion
  • lab data
    • 2022-04-12
      • LDH 776 U/L
      • beta-HCG >265200 mIU/mL
      • AFP 207.4 ng/mL
  • consultation
    • 2022-04-12 hemato-oncology
      • This 22-year-old male patient had past history of
        • Testis cancer status post operation at Tri-Service General Hospital for 2 years ago.
        • Pneumonia and lung abscess in 2021-12 at Taipei Tzu Chi Hospital
        • RLL and LLL solid nodules, suspected lung metastases on 20211229 at Tri-Service General Hospital.
      • This time, he suffered from headache and dizzness for one week. He was brough to our emergency room for help. Arrival at our emergency room, initial consciousness remained E4M6V5. Labortory data showed normal range of WBC, but elevated CRP (11.60mg/dl). Brain CT was done, which showed a 2.2cm heterogeneous hyperdense nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered. Brain MRI was performed, which revealed a 2.2cm rim-enhancing nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered. Multiple nodular and mass over bilateral lung were found. Consulted Neurosurgeon was done cause by suspected brain metastases of left cerebellum. He then admitted to SICU for neurological condition monitoring and further management on 2022-04-08. After SICU, he remained conscious during ICU stay. Under anti-swelling agent as Mannitol and Medason were used. PPI for ulcer prevention. Anticonvulsant agent as Keppra was given. He will arrange lung CT this afternoon.
        • Tumor marker: B-HCG: >265200, AFP:207.4, LDH:?
        • Chest CT: pending
        • Brain CT: left cerebellar metastasis.
        • Brain MRI: left cerebellar metastasis.
      • Impression:
        • Suspect recurrent nonseminal germ cell tumor with lung and brain metastasis
      • Suggestion:
        • Pending chest CT report, check LDH
        • Arrange CT guide biopsy for suspect lung metastasis
        • If proof recurrent non seminoma germ cell tumor, arrange port A insertion
        • Arrange pulmonary function test: FRC + DLCO
        • Wait for CT-guided biopsy of lung tumor that will be done on 4/14 22. If recurrent germ cell tumor wt lung mets & L cerebellar mets is Dx, palliative C/T will be started soon.
        • Germ cell tumor may be well responsive to palliative C/T wt BEP.
        • As for L cerebellar mets tumor, may consult radiation oncologist for R/T evaluation.
        • may check AFP, b-HCG as well.
    • 2022-04-08 Neurosurgery
      • Q:
        • cough with blood-tinged sputum for 2 weeks
        • headache with dizziness after waking up for one week
        • no fever, no sore throat or runny nose, no SOB, no chest pain
        • PMH: testis cancer s/p op, Rt lung cyst
        • allergy: denied
      • A:
        • A case of 22 y/o male; Testis cancer s/p; Headache/dizziness progressed for 1+ week;
        • A brain CT showed a 2.2cm heterogeneous hyperdense nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered.
        • A brain MRI with Gd showed a 2.2cm rim-enhancing nodule at left cerebellum, associated with vasogenic edema. Brain metastasis is first considered.
        • P: ICU care; mannitol/ steroid; Tumor excision indicated;
    • 2021-12-13 Radiological Diagnosis
      • Q: 22 year old male with past history of prostate cancer s/p OP 2 years ago admitted this time due to RLL pneumonia (suspected abscess) and treated with Brosym, Colistin, and Targocid. CT also showed an 1.3 cm nodule over left lower lungs. Thus, we needed your expertise for CT-giuded biopsy for left lower lung nodule.
      • A: This 22-year-old patient is a case of LLL nodule, r/o malignancy. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.

[assessment]

  • Not sure if orchiectomy has been performed.
  • Bleomycin + Etoposide + Cisplatin might be indicated.
  • Additionally, opioids may be a viable option for this patients with moderate to severe pain. (reference: https://www.ncbi.nlm.nih.gov/books/NBK554435/ )
  • Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered. The following interventions are available to treat cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
    • Epidural and selective nerve root block
    • Radiofrequency ablation and cryoablation
    • Vertebral augmentation
    • Intrathecal drug delivery
    • Spinal cord stimulation
    • Dorsal root ganglion stimulation

700803304

220420

{ovarian cancer}

  • history
    • Right ovarian cancer status post suboptimal debulking surgery (right salpingo-oophorectomy (RSO) + bilateral pelvic lymphadenectomy + cytoreductive surgery + infracolic omentectomy + Appendectomy) and hyperthermic intra-peritoneal chemotherapy on 2021-11-01.
    • Uterine myoma and left ovarian cyst s/p ATH + LSO
    • Type 2 diabetes mellitus with unspecified complications
  • exam finding
    • 2022-01-21 SONO - abdomen
      • Fatty liver, moderate
      • GB adenomatosis
    • 2021-11-21 CT
      • Focal small bowel ileus.
      • Colonic diverticula.
    • 2021-11-02 Patho - ovary (tumor)
      • Pathologic diagnosis
        • Ovarian tumor, right, frozen + debulking surgery - Carcinosarcoma and endometriosis
        • Pelvic tumor, debulking surgery - Tumor present
        • AJCC Pathologic staging: pT2bN0, if cM0, stage IIB
        • IHC
          • Carcinoma component: CK(+)
          • Sarcoma component: vimentin(+), CK(-), WT-1(-), ER(-), SMA(-), myogenin(-), CDK4(-), beta-HCG(-), CD10(+) and cyclin-D1(+, focal), CD31(+, focal)
          • Lymphovascular space invasion: present
    • 2021-10-27 CT - whole abdomen, pelvis
      • Right ovarian malignant tumor with carcinomatosis is highly suspected. Please correlate with CA125 and ascites cytology.
      • Right side obstructive uropathy is noted.
      • Several small lymph nodes in para-aortic and para-cava space.
  • surgical operation
    • 2021-11-01
      • HIPEC
      • Excision of intraabdominal tumor
      • Omentectomy
      • Appendectomy
      • Tenckhoff tube insertion
      • Right ovarian tumor, Frozen section: malignancy, type to be determined
      • status post Laparoscopic Assisted Vaginal Hysterectomy(LAVH) + Left Salpingo-oophorectomy (LSO)
  • chemotherapy
    • 2021-12 ~ ongoing: paclitaxel + carboplatin
    • 2021-10-30: Liposome doxorubicin + carboplatin

==========

2022-04-20

  • The patient was diagnosed with ovarian cancer following suboptimal debulking surgery on 2021-11-01, and has been treated with paclitaxel + carboplatin since December 2021.
  • The findings in the lab on 2022-04-20 were generally typical.
  • Readings of blood sugar in the ward fluctuated up to 430 mg/dL at 06:12 on 2022-04-21, which should be addressed (self-carried metformin has been prescribed on the active medication list). Additional insulin might be considered if blood sugar levels remain unruly.

2022-03-23

  • At present, the patient is receiving platin-based chemotherapy without intolerance during this hospital stay; no apparent abnormalities were found in laboratory results reported on 2022-03-22.
  • Blood sugar readings tested in the ward fluctuated up to 211 mg/dL at 06:30 on 2022-03-23, which should be addressed (self-carried metformin has been prescribed in active medication list).

2022-03-02

  • the patient is currently receiving platin-based chemotherapy without intolerance.
  • most recent HbA1c recorded 7.3% on 2021-10-27, blood sugar tested 328mg/dL at 06:48 on 2022-03-02, metformin prescribed at Metab & Endoc OPD might be considered if needed.

700127501

220419

[objective]

  • exam finding
    • 2022-03-30 Esophagogastroduodenoscopy
      • Diagnosis:
        • Reflux esophagitis LA grade A
        • Superficial gastritis
        • Gastric erosions, body, GC
        • Doudenal ulcers with duodenitis, bulb to 3rd portion
        • Incomplete study of esophagus due to residual food
      • Suggestion:
        • Pursue CLO test result
    • 2022-03-27 Sacrum & coccyx
      • mild spondylolisthesis at L5-S1
      • moderate decreased L5/S1 joint space
    • 2022-03-27 L-spine Lat
      • loss of the natural curvature of the spine
      • mild spondylolisthesis at L5-S1
      • severe decreased disc space in the L5/S1 disc
      • unremarkable change in the paravertebral region
      • compression racture at T11 vertebral body
    • 2022-03-27 CT - abdomen, pelvis
      • suspected duodenal perforation
    • 2022-02-16 CT - lung/mediastinum/pleura
      • breast cancer with hematogeneous and lymphatic metastases in both lungs, and spine metastasis, and bilateral pleural effusions, in progression as compared with previous CT on 20210921.
      • suspect associated with infection or drug toxicity in the lungs.
    • 2022-02-15 Chest
      • S/P port-A implantation.
      • Multiple nodular opacity projecting in the both lung are noted that may be metastases. Please correlate with CT.
      • Presence of old fracture(s) at the bil. ribs and right clavicle are noted that may be bony metastases? Please correlate with CT.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura thickening or effusion?
      • Atherosclerotic change of aortic arch
    • 2021-09-21 CT - chest
      • S/P right breast operation. Bil. lung metastases.
      • Suspected metastases at T10.
    • 2021-09-10 Chest
      • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
      • Multiple ill-defined nodules of variable sizes and reticular abndormality throughout in both lungs due to metastases.
      • A large increased opacity shadow over lateral Rt hemithorax, extrapulmonary lesion
      • Absence of medial half of Rt clavicle and focal bone defects at Rt humeral head
      • Old fracture of many Lt ribs
      • Osteoblastic metastasis in spine
    • 2021-08-16 KUB
      • Fecal material store in the colon.
    • 2021-05-21 CT - lung/mediastinum/pleura
      • S/P mastectomy at right side.
      • Diffuse lung meta, stationary.
      • Right humoral head bony invasion. Stable.
      • Bone mets at lumbar spine
    • 2021-02-06 CT - lung/mediastinum/pleura
      • Compatible with breast cancer lung meta, stationary in lung mets.
      • Bone mets at right clavicle. stable.
    • 2020-12-14 Pathology - bronchus biopsy
      • Diagnosis
        • Lung, side?, CT-guide biopsy — metastatic breast carcinoma of no special type
      • Microscopic Description
        • Section shows cores of alveolar lung tissue with irregular neoplastic glands infiltration.
        • IHC: GATA3(+) and TTF-1(-). The results are consistent with metastatic breast carcinoma of no special type.
      • Immunohistochemical Study
        • ER (Ab): Positive(95%, strong)
        • PR (Ab): Negative
        • Her-2/neu (Ab): Negative (1+)
        • Ki-67: 20%
    • 2020-10-23 CT - lung/mediastinum/pleura
      • Breast cancer with bilatral lung mets and right clavicle mets.
    • 2020-10-15 CT - brain
      • Mild brain atrophy and intracranial atherosclerotic disease
    • 2020-09-14 ABR, Auditory brainstem evoked response
      • R’t 60 dB nHL
      • L’t 55 dB nHL
    • 2020-03-13 CT - lung/mediastinum/pleura
      • Diffuse lung mets and bone mets. In progression.
    • 2019-07-17 CT - lung/mediastinum/pleura
      • Breast cancer with lung metastasis with fibrosis, slightly in progression.
    • 2018-01-30 CT - lung/mediastinum/pleura
      • Breast cancer with lung metastasis, stationary.
    • 2017-10-25 CT - lung/mediastinum/pleura
      • Lung metastasis still present.
    • 2017-03-23 SONO - breast
      • A small right breast calcification.
      • Post OP with Edema at right axillary region.
      • Small left breast nodules and cysts.
      • BI-RADS: 2, Benign findings
    • 2017-03-21 CT - lung/mediastinum/pleura
      • D/D lung edema and/or pulmonary lymphagitic carcinomatosis.
      • LVD of heart.
      • Rt shoulder and arm post treatment change or edema.
    • 2017-02-17 Tc-99m MDP whole body bone scan
      • Increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in the right shoulder, left sternoclavicular junction, right elbow, right wrist, bilateral knees and right foot. Either benign joint lesion such as arthritis or post-traumatic change may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • No prominent bone abnormality was noted elsewhere.
    • 2008-07-14 CT
      • bilateral multiple pulmonary metastasis
      • pT2N2M1, stage IV
    • 2008-06 Pathology
      • Infiltrating ductal carcinoma, grade II with pectoralis major muscle invasion
      • IHC: ER(+) 5% score 1, PR(+) 20% score 1, Her2(-)
  • surgical operation
    • 2008-06-16 MRM at Taipei City Hospital FuYou Branch
  • chemotherapy
    • 2022-03-15 ~ undergoing - ribociclib
    • 2020-12-25 ~ undergoing - exemestane
    • 2017-02-03 ~ 2020-12-18 - letrozole
    • 2008-07-10 ~ 2008-09-16 doxorubicin + cyclophosphamide; (then docetaxel, letrozole, vinorelbine?)

==========

2022-04-19

[tube feeding]

  • All oral PPIs should not be ground.
  • PPIs are easily protonated and therefore unstable at acid pH. In gastric juice, this would result in inactivation before absorption. This is why some PPIs are enteric coated. Following absorption, they partition by ionic trapping into the acidic environment of the parietal cell cytoplasm, where the unstable sulphonamide/sulphenic acid species that result from protonation form irreversible disulphide bonds with cysteine residues in the proton pump.
  • Pariet FC (rabeprazole 20mg/tab) is film-coated and not intended for tube feeding. It could be replaced with Takepron (lansoprazole 30mg/tab), Nexium (esomeprazole 40mg/tab) or Dexilant (Dexlansoprazole 60mg/cap), with opening the capsule and pouring out the small granules into drinking water prior to tube feeding.

2022-04-18

  • This patient was diagnosed with breast cancer (ER+ PR- HER2-, 2020-12-14 pathology, s/p MRM) with lung and spine mets in progress (2022-02-16 CT) and was treated with exemestane since 2020-12-25, and with ribociclib since 2022-03-15.
  • The current regimen (aromatase inhibitor and CDK4/6 inhibitor) is a treatment of choice for HR+ HER2- postmenopausal recurrent or stage IV breast cancer.
  • All the listed underlying health conditions have been managed with corresponding drugs. As TPR readings remain relatively stable, blood sugar readings fluctuate at a higher range, which should be addressed.
  • Kisqali (ribociclib) prescribed at 2022-04-15 OPD has been filled to 2022-04-29. Severe, life-threatening, and/or fatal interstitial lung disease (ILD) and/or pneumonitis may occur with ribociclib (and other cyclin-dependent kinase inhibitors). Symptoms of ILD/pneumonitis may include hypoxia, cough, dyspnea, or interstitial infiltrates on radiologic exam. (exclude infectious, neoplastic, and other causes for pulmonary toxicity.) Kisqali (ribociclib) is currently suspended.

700379547

220419

{Recurrent hepatocellular carcinoma with Lung and C-spine, T-spine and L-spine metastasis cT2N0M1 stage IV}

[objective]

  • exam finding
    • 2022-04-01 KUB
      • S/P operation with retention of surgical clips.
      • Stool retention in the bowel.
      • Degeneration and spondylosis of L-S spine.
    • 2022-03-18 CT - abdomen, pelvis
      • Multiple bony metastases on the T-and L-spine, and bilateral ilium show progressive disease.
      • Compression fracture of L5 vertebral body is noted.
      • Right lower Lung metastases show progressive disease.
    • 2022-02-25 Patho - omentum biopsy
      • diagnosis
        • Tissue, site unspecified, CT-guide biopsy — hepatocellular carcinoma
        • Microscopically, it shows hepatocellular carcinoma composed of neoplatic cells with hyperchromatic nuclei, fine granular cytoplasm, arranged in trabecular pattern with greater than 3 cell thick cords.
        • IHC: CK7(-), CK19(-), arginase(+), CD10(-), and hepatocytes(+).
    • 2022-02-25 Tc-99m MDP whole body bone scan
      • The scintigraphic findings suggest multiple bone metastases.
    • 2022-02-18 MRI - upper abdomen
      • Multiple HCCs at left hepatic lobe are noted.
      • Multiple bony metastases on the T-and L-spine are suspected.
      • Lung metastasis 1.1 cm at RLL is noted.
    • 2022-01-11 CT - liver, spleen, biliary duct, pancreas
      • Post-op at right lobe liver.
      • Diffuse HCCs, progression.
      • Lung and bone metastasis.
      • Suspected left renal cysts, up to 2.1cm.
    • 2021-12-15 CT - liver, spleen, biliary duct, pancreas
      • Multiple HCCs at left hepatic lobe are suspected.
      • Lung metastasis 1.1 cm at RLL is highly suspected.
    • 2021-10-14 CT - liver, spleen, biliary duct, pancreas
      • S/P liver operation. Several recurrent HCCs (0.3-0.9) at remnant liver.
      • A nodule (9mm) at RLL r/o metastases.
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2021-09-01 CT - liver, spleen, biliary duct, pancreas
      • Two viable HCCs 1.1 cm in S2 and 0.7 cm in S4 are suspected.
      • Two recurrent HCCs 0.6 cm and 0.5 cm in S4 are suspected.
      • Cirrhosis of the liver with portal hypertension.
    • 2021-07-21 CT - liver, spleen, biliary duct, pancreas
      • Two recurrent HCCs 1.8 cm in S2 and 0.7 cm in S4 are highly suspected. Please correlate with AFP.
      • Cirrhosis of the liver with portal hypertension.
    • 2021-06-02 CT - liver, spleen, biliary duct, pancreas
      • Two recurrent HCCs 1.6 cm in S2 and 0.7 cm in S4/8 are highly suspected. Please correlate with AFP.
      • Prior CT identified HCC in S4/8 of the liver S/P TACE on 20210513 shows complete response.
      • Cirrhosis of the liver with portal hypertension.
    • 2021-05-19 Abdominal Ultrasonography
      • Liver tumors, suspected recurrent HCCs
      • Liver cirrhosis with mild splenomegaly
      • Liver lesions, spspect tumor scars or regeneration nodules
      • Invisible GB
    • 2021-05-06 CT - liver, spleen, biliary duct, pancreas
      • S/P liver operation. Two recurrent HCCs (1.1cm, 1.3cm, srs3, img13, 15) at S2 and right liver margin.
      • A nodule (6mm) at RLL r/o metastases.
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2021-02-25 Patho - liver partial resection
      • Pathologic diagnosis
        • Liver, S6-7, segmentectomy — Hepatocellular carcinoma, recurrent
        • Pathologic Staging: rpT2Nx(cM0), Stage II at least
    • 2021-02-03 MRI - liver, spleen
      • Imaging stage: T2N0M0, stage II
    • 2020-11-03 CT - liver, spleen, biliary duct, pancreas
      • S/P RFA and S/P cholecystectomy.
      • Post-op at left lobe liver with focal enhancement at S4 around the surgical region, probably vascular shunting. Suggest clinical correlation and follow up study.
      • Renal cysts.
      • Minimal ascites in the pelvic cavity.
    • 2020-09-21 CT - abdomen, pelvis
      • Long segmental wall edema of esophagus and duodenum. Distention of stomach.
      • S/P liver operation and cholecystectomy. Liver cirrhosis.
    • 2020-08-17 MRI - liver, spleen
      • Liver cirrhosis with portal hypertension and splenomegaly. HCC s/p operation and RFA without tumor recurrence.
    • 2020-06-17 CT - liver, spleen, biliary duct, pancreas
      • Liver cirrhosis with HCC at S6 s/p RFA. No evidence of local recurrence is found.
    • 2020-03-16 CT - liver, spleen, biliary duct, pancreas
      • HCCs s/p operation, TACE and RFA. Residual and recurrent HCCs (3-8mm) at right hepatic lobes.
    • 2020-02-04 Embolization (TAE) - abdomen
      • HCCs at RIGHT hepatic lobe s/p TACE.
    • 2019-11-28 MRI - liver, spleen
      • Liver cirrhosis.
      • HCC at S6 s/p RFA with recurrent tumor adjacent to the lesion. Suggest further treatment.
    • 2019-09-18 CT - liver, spleen, biliary duct
      • Liver cirrhosis with HCC s/p RFA and TACE, no evidence of local recurrence in the study.
    • 2019-07-03 CT - liver, spleen, biliary duct
      • Liver cirrhosis.
      • HCC s/p op. and RFA with suspected tumor recurrence at S7. Malignant liver neoplasm, primary;
    • 2019-05-20 Surgical pathology Level V
      • Liver, sono-guided biopsy — Consistent with hepatocellular carcinoma and liver cirrhosis
      • The sections show a picture liver cirrhosis, composed of regenerative nodules separated by broad fibrous bands. Scant atypical cells arranged in thin trabecular pattern can be found.
      • IHC: Glutamine synthetase(+), HSP70(+), glypican-3(+) and CK7(-). The IHC finding is consistent with hepatocellular carcinoma.
    • 2019-03-12 CT - liver, spleen, biliary duct
      • S/P operation. A recurrent HCC (9mm) in S6 of liver.
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2018-09-07 Surgical pathology Level V
      • pathologic diagnosis
        • Liver, S5, partial hepatectomy — Hepatocellular carcinoma
        • Liver, S6, partial hepatectomy — Combined hepatocellular-cholangiocarcinoma
        • Specimen labeled “surface tumor”, frozen section — Regenerative nodule
        • Pathologic Staging: ypT2Nx(cM0), Stage II at least
      • microscopic examination
        • Diagnosis: Hepatocellular carcinoma(S5) and combined hepatocellular-cholangiocarcinoma(S6)
        • Histologic Grade: G2 (Moderately differentiated, both tumors)
        • Tumor Extension: Tumor confined withing liver (both tumors)
        • Pathologic Stage Classification
          • Primary Tumor (pT): ypT2 (multiple tumors, none >5 cm)
          • Regional Lymph Nodes (pN): ypNx (No lymph nodes submitted)
          • Distant Metastasis (pM): Not applicable
        • Additional Pathologic Findings: Chronic hepatitis C
        • Ishak modified staging of fibrosis: Cirrhosis (F6)
        • IHC: Cholangiocarcinoma component reveals CK7(+), Hepa1(-), Arginase-1(-)
    • 2017-07-10 MRI - liver, spleen
      • HCC s/p RFA. A poor enhancing nodule (1.5cm) in S6 of liver without interval change.
      • Liver cirrhosis with regenerative nodules, portal hypertension and splenomegaly.
    • 2017-02-16 CT - liver, spleen, biliary duct
      • HCC s/p RFA. Liver cirrhosis with splenomegaly.
  • lab data
    • 2021-08-13 PIVIKA-II 62.36 mAU/mL (normal < 40)
  • surgical operation
    • 2021-12-17 Embolization (TAE) - abdomen for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-11-03 Embolization (TAE) - abdomen for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-09-02 Embolization (TAE) - abdomen for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-07-22 Embolization (TAE) - abdomen for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-06-21 Embolization (TAE) - abdomen for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-05-13 Embolization (TAE) - abdomen for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-02-24
      • surgery - laparoscope assist right posterior segmntectomy S6-7
      • finding - two hepatic tumors at S7 and scaring at S6 and S6 postresected scarring
    • 2020-05-29 RFA, Radiofrequency ablation - HCC
    • 2020-05-06 PEIT, Sonography guided percutaneous ethanol injection
    • 2019-08-23 Embolization (TAE) - abdomen
      • HCCs at RIGHT hepatic lobe s/p TACE.
    • 2018-09-06 Partial Hepatectomy
  • chemoimmunotherapy
    • 2020-05-05 ~ 2022-01-10 - nivolumab
    • 2020-04-01 ~ 2021-03-19 - lenvatinib

[assessment]

  • This patient underwent partial hepatectomy on 2018-09-06, PEIT on 2020-05-06, RFA on 2020-05-29, 7 times of TACE between 2019-08-23 and 2021-12-17, and Lenvatinib from 2020-04-01 to 2021-03-19 as well as Nivolumab from 2020-05-05 to 2022-01-10. The patient’s disease has progressed based on 2022-03-18 CT.
  • Historically, traditional chemotherapy agents have not shown great efficacy in the treatment of HCC when used in advanced stage of disease, in particular in case of progression after locoregional therapy. FOLFOX is listed in NCCN HCC guideline as a category 2B regimen. In the event of MSI-H/dMMR being proven, dostarlimab-gxly might be tried (also category 2B).

701361740

220415

{Acute myeloid leukemia}

[objective]

  • exam finding
    • 2022-03-22 Patho - bone marrow biopsy
      • Bone marrow, iliac bone, biopsy — Acute myeloid leukemia
      • Microscopically, the sections show a picture of acute myeloid leukemia, no remission, composed of hypocellular marrow for her age (20-30%). The blasts are small-sized with round nuclei, and small amount of cytoplasm, 70-80% of nucleated cells.
      • Immunohistochemistry shows CD34(+), CD117(+) and MPO(-) for blast, CD61(+, megakaryocytes) and CD71(+, erythroid series) revealed hypoplasia of megakaryocyte and erythroid series.
    • 2022-02-22 Abdominal Ultrasonography
      • Indication: pancytopenia
      • Diagnosis: possible liver lesion or false lesion, S5/8
    • 2022-02-21 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Compatible with acute myeloid leukemia
      • The sections show normocellular marrow (35%). The marrow space is partially replaced by a population of medium-sized immature cells with oval nucleus and high N/C ratio, constitue 50% of marrow cells.
      • IHC, the immture cells reveal: CD34(+), CD117(+), TdT(rare+), CD3(-), CD20(-), CD79a(-). The finding is compatible with acute myeloid leukemia. Suggest bone marrow smear study and flow cytometry evaluation.
  • lab data
    • 2022-03-11
      • HLA A-high 11:01
      • HLA B-high 39:01
      • HLA C-high 07:02
      • HLA DRB1
        • HLA DQ-high 04:02, 06:01
        • HLA DQ-high 04:10, 08:03
    • 2022-03-04
      • FLT3/ITD mutation undetectable
      • NPM1 mutation undetectable
    • 2022-03-03 Aspiration
      • CD2 NA
      • CD3 1.53
      • CD4 NA
      • CD5 0.25
      • CD7 0.15
      • CD8 NA
      • CD10 0.82
      • CD11b 59.4
      • CD13 76.3
      • CD14 0.13
      • CD15 NA
      • CD16 0.9
      • CD19 19.16
      • CD19/kappa NA
      • CD19/Lambda NA
      • CD20 0.23
      • CD23 NA
      • CD25 NA
      • CD33 87.26
      • CD34 98
      • CD38 NA
      • CD56 0.15
      • CD103 NA
      • CD117 0.04
      • CD138 NA
      • FMC7 NA
      • HLA-DR 99.76
      • MPO NA
      • TdT NA
  • chemotherapy
    • 2022-03-04 ~ undergoing - idarubicin + cytarabine, 3 + 7

==========

2022-04-15

  • The patient almost 60 was recently diagnosed with AML and has been receiving idarubicin and cytarabine (3 + 7) since 2022-03-04.
  • For patients with AML, FLT3/ITD marks poor survival in younger (<60 years) but not in older (60-74 years) and NPM1 mutation marks good survival in older, but not younger. reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7094014/
  • The patient’s lab results of FLT3/ITD and NPM1 were undetectable (2022-03-04), not revealing much direction in terms of risk stratification.
  • Neutropenic fever and HBV are treated with corresponding ABX and entecavir, respectively. No issue with current medication.

2022-03-23

[Quinolones-Antacids Interactions]

objective

  • Drugs listed in current medication
    • Cravit (levofloxacin 500mg/tab) 1.5 tab PO QDAC
    • Strocain (oxethazaine, polymigel i.e. aluminum hydroxide + calcium carbonate + magnesium carbonate) 5mg/tab 1 tab PO TIDAC

assessment

  • Antacids may decrease the absorption of quinolones in the setting of oral administration of quinolones.
    • Antacids interacting members: Almagate, Aluminum Hydroxide, Calcium Carbonate, Diomagnite, Magaldrate, Magnesium Carbonate, Magnesium Hydroxide, Magnesium Trisilicate, Potassium Bicarbonate
      • Exception: Sodium Bicarbonate
    • Quinolones interacting members: Ciprofloxacin (Systemic), Delafloxacin, Enoxacin, Gemifloxacin, Levofloxacin (Systemic), Lomefloxacin, Moxifloxacin (Systemic), Nalidixic Acid, Norfloxacin, Ofloxacin (Systemic), Pefloxacin, Pipemidic Acid, Sparfloxacin, Zabofloxacin
      • Exception: Levofloxacin (Oral Inhalation)

suggestion

  • Either administration of Cravit 30 minutes before Strocain or lowering of Strocain to QLAC + QNAC is recommended.

701328847

220413

  • diagnosis
    • Mantle cell lymphoma involving in bilateral neck lymph nodes, supraclavicular lymph nodes, mediastinal and bilateral pulmonary hilar lymph nodes and some bilateral axillary lymph nodes and the soft tissue in the right buttock, bone marrow(+), PS:0, Lugano stage IV, MIPI 6.7, high risk, HCT-CI score:0 (low risk, non-relapse mortality 14% at 2years)
  • exam finding
    • 2022-03-18 CT - lung/mediastinum/pleura
      • Mild splenomegaly
      • No evidence of lymphadenopathy in the study.
      • Dilated aortic root.
    • 2022-02-08 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Consistent with myelodysplastic syndrome
      • Sections show 30-50 % cellularity with marked decreased erythroid cells. Atypical small and hypolobated megakaryocytes are found about 3-8/HPF. Some megakaryocytes are positive for CD34. The CD34 and CD117 show no increased blasts. The immunohistochemical stain of Hemoglobin A show scant residual erythroid cells. The immunohistochemical stains of CD3 and CD20 show some CD3-positive lymphocytes without CD20-positive lymphocytes.
      • The morphology is consistent with myelodysplastic syndrome.
    • 2022-01-13 MRA - brain
      • Cerebral white matter FLAIR-hyperintensitie. Suspected demyelineation process due to ischemia or chemotherapy.
    • 2021-12-17 CT - lung/mediastinum/pleura
      • No evidence of lymphadenopathy in the study but borderline splenomegaly is noted.
    • 2021-09-16 Patho - bone marrow biopsy
      • diagnosis
        • Bone marrow, iliac, clinically: newly diagnosed in China with first time chemotherapy), biopsy — Mantle cell lymphoma.
        • IHC: CD3(-), CD20(+), bcl-2(+), bcl-6(-), Cyclin-D1(focal +).
      • microscopic description
        • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are multiple minute aggregates of small atypical lymphoid cells.
    • 2021-09-07 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma of low to median FDG uptake involving multiple lymph nodes on the same side of the diaphragm as mentioned above (stage II).
      • Mildly increased FDG uptake in a focal area in the soft tissue in the right buttock. The nature is to be determined (inflammation? other nature?).
      • Increased FDG accumulation in both kidneys and left ureter. Physiological FDG accumulation is more likely.
    • 2021-09-07 CT - neck
      • Multiple enlarged bil. neck LNs, esp. at right posterior cervical space, supraclavicular fossa and axilla.
  • chemoimmunotherapy
    • 2022-02-15 - ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin)
    • 2022-02-14 - rituximab
    • 2021-12-28 - R-DHAP
      • R - rituximab (also called Mabthera), a type of targeted cancer drug called a monoclonal antibody
      • DH - dexamethasone, which is a steroid
      • A - cytarabine (also known as Ara C), a chemotherapy drug
      • P - cisplatin, a chemotherapy drug
    • 2021-12-01 - R-CHOP, rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride (doxorubicin hydrochloride), vincristine (Oncovin) and prednisone
    • 2021-11-08 - R-DHAP
    • 2021-09-16, -10-12 - R-CHOP
    • 2021-08-04 - R-CHOP (in mainland China)
  • consultation
    • 2022-01-12 Neurology
      • Assessment
        • Peripheral vertigo, suspected platinum based chemotherapy related
      • Suggestion
        • Arrange BAEP, Intracranial and carotid doppler ultrasound, check BP at lying, sitting and standing with 3 minutes interval each position.
        • Use diphenidol and meclizine routinely.
        • MRA brain with/without contrast may be arranged if new neurological deficit occured.

==========

2022-04-13

[Interprofessional Practice Meeting and Family Meeting]

  • The postponed meeting rescheduled at 10:30 2022-04-13 in the ward, the patient was present, as was her son.
  • Dr. Kao explained the treatment plan of the disease to the patient family, as well as the prognosis and possible risks, and interprofessional practice team members were present for inquiries.

2022-04-12

[mesna administration]

  • mesna administration via ntravenous route
    • dilute with D5W, NS, LR, D5-0.2%NaCl, D5-0.33%NaCl, or D5-0.45%NaCl to a final concentration of 20 mg/mL
    • following initial puncture of multidose vial, use within 8 days
    • following dilution, store at 25 degrees C and use within 24 hours
    • do not mix with epirubicin, cyclophosphamide, cisplatin, carboplatin, or nitrogen mustard
    • if mixed with ifosfamide in the same IV bag, do not exceed a final ifosfamide concentration of 50 mg/mL
  • the patient is 50kgw, scheduled dose is 12mg/kg, 600mg should be dissolved in at least 30mL aforementioned solvent, injection 30 min is recommended.

2022-04-11

  • The arranged IPP meeting (TP1110411001) has been postponed until further notice.
  • There is no TP53 mutation lab data found.
  • The patient has been treated with RCHOP, alternating RCHOP/RDHAP, R-ESHAP during Aug 2021 to Feb 2022.
  • The results of two consecutive bone marrow biopsies revealed mantle cell lymphoma (2021-09-16) and myelodysplastic syndrome (2022-02-08). High-dose therapy (HDT) and autologous stem cell rescue (ASCR) might be indicated. There will be a patient family meeting to discuss ASCR in the near future.
  • During this hospital stay, phenytoin was prescribed to prevent intravenous busulfan induced seizures in recipients of hematopoietic cell transplantation. Phenytoin is primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine, making routine dose adjustments for kidney dysfunction unnecessary. Lab results reported on 2022-04-11 indicated slight elevations of ALT (44 U/L, normal < 41) and creatinine (1.4 mg/dL, normal < 1.3), which did not require adjusting the pheytoin dose.

2022-01-11

[objective]

Creatinine lab data: - 2022-01-10 1.25mg/dL - 2022-01-07 1.43mg/dL - 2022-01-03 0.93mg/dL

[assessment]

  • serum creatinine elevates slightly above normal range during ABX administration.

[suggestion]

  • no immediate dose adjustment needed for now, keep monitoring renal function as regular to check the trend.

700306021

220412

[objective]

  • exam finding
    • 2022-03-14 Patho - pancreas biopsy
      • Labeled as pancreatic head, EUS fine needle biopsy - adenocarcinoma.
      • Section shows core of tissue with irregular neoplastic glands and markedly desmoplastic stroma.
      • IHC stains: CK19(+), CA19-9(+), CD56(-), p40(-).
    • 2022-03-14 Fine needle aspiration cytology - pancreas
      • Pancreatic head tumor: adenocarcinoma
    • 2022-03-11 Endoscopic Retrograde CholangioPancreatography, ERCP
      • Pancreatic head tumor with CBD invasion, s/p TPS, s/p ERBD
      • Marked dilatation of biliary tree
      • Inadvertent performance of partial pancreatography
    • 2022-03-11 Endoscopic ultrasonography
      • Diagnosis
        • Pancreatic head tumor, s/p EUS/FNB
        • Tumor invasion of CBD with marked biliary dilatation
        • Gastric shallow ulcers and erosions, antrum
        • Hiatal hernia
      • Suggestion
        • Pursue pathology and cytology result
        • Give PPI after the procedure
    • 2022-03-10 MRI - pancreas
      • Pancreatic head cancer (3.3cm) with common hepatic artery, SMA, SMV, proximal main portal vein, CBD, p-duct. duodenal invasion and LNs metastases (T4N1M0, stage III).
    • 2022-03-10 Echocardiography
      • Dilated LA, LV
    • 2022-03-08 MRI - pancreas
      • In favor of pancreatic head tumor with SMA, SMV, portal vein, distal CBD, p-duct and duodenal invasion. Some LNs at hepatic hilar region.
    • 2022-03-07 Endoscopic ultrasonography
      • Pancreatic tumor with cystic components, head, probable pancreatic cancer
      • MPD dilatation
      • CBD dilatation and sludge
      • Distended GB with sludge
      • Esophageal erosion, lower esophagus
    • 2022-03-07 Abdominal sonography
      • Pancreatic head tumor, suspected cancer
      • Bilateral IHD and CBD dilatation
      • Distented gallbladder
    • 2022-03-05 CT - liver, spleen, biliary duct, pancreas
      • Soft tissue mass at uncinate process of the pancreas with obliteration of the CBD up to 2.09cm is found, causing IHDs and CBD dilatation. Pancreatic cancer is suspected. The SMV is attached by the tumor.
    • 2020-07-06 MRA - brain
      • T2 hyperintensities in bilaetral white matter and periventricular region, suspected chronic ischemic or other demyelinating white matter change.
      • Brain atrophy.
  • consultation
    • 2022-03-08 Gastroenterology & General Surgery
      • Impression
        • Pancreatic head tumor, IHDs and CBD dilatation
      • Suggestions:
        • Insert PTCD/endo stent first due to hyperbilirubinemia.
        • Check blood sugar HbA1c, glucose AC/PC.
        • Arrange cardiopulmonary function tests such as cardiac echo and lung function test due to old age.
        • We will evaluate the need of the operation after her hyperbilirubinemia subsided.
  • radiotherapy
    • 2022-03-29 ~ 2022-04-11 - 720cGy/4 fractions (15 MV photon) to pancreatic head tumor and lymphatics
    • Neoadjuvant C/T and R/T for 5040cGy/28 fractions is sugested for downstage and tumor control.
  • chemotherapy
    • 2022-03-28 ~ undergoing - FOLFIRINOX, pre-Op neoadjuvant C/T
      • oxaliplatin 50mg/m2 2hr
      • irinotecan 90mg/m2 2hr
      • leucovorin 400mg/m2
      • 5-Fu 2000mg/m2 46hr

[reference]

  • FOLFOXIRI vs FOLFIRINOX as first-line chemotherapy in patients with advanced pancreatic cancer: A population-based cohort study. https://dx.doi.org/10.4251/wjgo.v12.i3.332
    • FOLFIRINOX was administered according to the standard schedule validated by the PRODIGE 4/ACCORD 11 study. This regimen consisted of a combination of oxaliplatin (85 mg/m2, over 2 h), followed by leucovorin (400 mg/m2, over 2 h), with the addition through a Y-connector, after 30 min, of irinotecan (180 mg/m2, over 90 min), followed by 5-FU (400 mg/m2) by intravenous bolus, on Day 1. Then, a continuous intravenous infusion of 5-FU (2400 mg/m2) was administered over 46 h starting on Day 1.
      • oxaliplatin 85mg/m2 2hr
      • leucovorin 400mg/m2 2hr
      • irinotecan 180mg/m2 90min
      • 5-FU 400mg/m2 IV bolus
      • 5-FU 2400mg/m2 46h
    • FOLFOXIRI consisted of the same molecules with a reduced dose of irinotecan and no bolus 5-FU, according to the GONO regimen used in metastatic colorectal cancer: Irinotecan (165 mg/m2, over 1 h), followed by oxaliplatin (85 mg/m2) and leucovorin (200 mg/m2) concomitantly over 2 h through a Y‐connector, on Day 1; and followed by a continuous intravenous infusion of 5-FU (3200 mg/m2) over 48 h starting on Day 1.
      • irinotecan 165mg/m2 1hr
      • oxaliplatin 85mg/m2
      • leucovorin 200mg/m2 2hr
      • 5-FU 3200mg/m2 48hr

[assessment]

  • There is a case of pancreatic head cancer with common hepatic artery, superior mesenteric artery, superior mesenteric vein, proximal main portal vein, CBD, pancreatic duct, duodenal invasion and lymph node metastases (2022-03-10 MRI).
  • If jaundice is present, placement of a self-expanding metal stent is recommended, preferably via ERCP. ERBD was performed via ERCP on 2022-03-11. Bilirubin total decreased from its peak of 13.75mg/dL on 2022-03-07 to 1.86mg/dL on 2022-04-11.
  • The patient has been given 720cGy/4 fractions (15 MV photon) to treat the pancreatic head tumor and lymphatics (2022-03-29 to 2022-04-11) and has been receiving neoadjuvant FOLFIRINOX to downstage the tumor since 2022-03-28.
  • Tumor/somatic gene profiling is recommended for patients with locally advanced/metastatic disease who are candidates for anti-cancer therapy to identify uncommon mutations. Consider specifically testing for actionable somatic findings including, but not limited to: fusions (ALK, NRG1, NTRK, ROS1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and mismatch repair (MMR) deficiency (detected by tumor IHC, PCR, or NGS). Testing on tumor tissue is preferred; however, cell-free DNA testing can be considered if tumor tissue testing is not feasible.
  • The laboratory results reported on 2022-04-11 showed normal ALT and creatinine readings as well as lower WBC (2930/uL, Neutrophil 58%), which should not affect the chemotherapy treatment in this hospital stay.
  • No drug allergy records found in database, no issue with current medication.

700026574

220411

{Left renal cell carcinoma with metastatic mediastinal lymphadenopathies and suspecious RUL lung metastasis, liver and bone metastases s/p chemotherapy and radiotherapy}

[objective]

  • exam finding
    • 2022-04-10 Pelvis THR & Rt Hip Lat; KUB & L-spine
      • Lucent lesions in L5, S1, right acetabulum.
    • 2022-04-10 CT - abdomen
      • Bony metastases.
      • Dilatation of A- and T-colon.
      • Collapse of gallbladder with small stones (2-3mm). Small CBD stones (2-3mm).
    • 2022-04-10 Chest
      • Presence of ileus.
      • Fracture of right ribs with union.
      • Ground glass opacity in right lung.
    • 2022-04-01 Chest
      • Several nodular opacity projecting in the right upper lung are suspected. Please correlate with CT.
      • Left hemi-diaphragm elevation was noted that is compatible with bronchiectasis with collapse after correlate with CT.
      • Atherosclerotic change of aortic arch.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening.
    • 2022-02-23 Tc-99m MDP bone scan with SPECT
      • In comparison with the previous study on 20200911, some new bone lesions in both rib cages are noted, suggesting multiple bone metastases in progression. However, several previous bone lesions in multiple T- and L-spine, sternum, right humeral head, and right iliac bone become less evident, indicating partial respopnse to current therapy.
      • Suspected benign lesions at bilateral knees.
    • 2022-02-22 CT - abdomen, pelvis
      • Bone meta at left rib, L5 and right acetabulum, Suggest further treatment.
    • 2022-02-21 KUB
      • Fracture of right acetabulum is suspected.
    • 2020-09-11 Tc-99m MDP bone scan
      • In comparison with the previous study on 20200407, some new bone lesions are noted and some of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
      • No prominent change is noted in the lower C-spine and right sternoclavicular junction. Degenerative change may show this picture.
    • 2020-04-22 Chest
      • A nodular opacity projecting in the ventral aspect of RUL of the lung is suspected that is compatible with metastasis after correlate with chest CT.
      • Band-like atelectasis in RLL and LUL of the lung.
      • Patchy opacity projecting at the left lower medial lung zone and Left hemi-diaphragm elevation was noted that is compatible with bronchiectasis with collapse after correlate with CT.
      • Atherosclerotic change of aortic arch.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening.
    • 2020-04-07 Tc-99m MDP bone scan
      • Prominently increased activity in the L5 spine, sternum and right iliac bone. Bone metastases should be considered. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the lower C-spine, some middle and lower T-spines, right sternoclavicular junction and right humeral head. Either degenerative change or bone metastases may show this picture. Please keep follow-up for further evaluation.
      • Some hot and faint spots in bilateral rib cages and mildly increased activity in the lesser trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastasis? other nature?).
    • 2020-03-18 MRI - L-spine
      • tumors in the L5 and right iliac bone.
    • 2019-12-13 CT - lung/pleura, chest and upper abdomen
      • Compatible with RCC lung meta and mediastinal lymph nodes, stable.
    • 2019-09-11 CT - lung/pleura, chest and upper abdomen
      • no mediastinal LAP and no lung nodule on this F/U study.
      • stationary atelectatic basal segments with air-bronchograms of the LLL.
    • 2019-06-06 CT - lung/pleura, chest and upper abdomen
      • no mediastinal LAP and no lung nodule on this F/U study.
      • stationary atelectatic basal segments with air-bronchograms of the LLL.
    • 2019-03-06 CT - chest and upper abdomen
      • RCC with resolution of left lung and mediastinal LNs metastasis as compared with previous CT study.
    • 2018-11-21 CT - chest and upper abdomen
      • RCC with left lung and mediastinal LNs metastasis, further in regression as compared with previous CT study.
    • 2018-08-23 CT - chest and upper abdomen
      • RCC with lung and mediastinal LNs metastasis, further in regression as compared with previous CT study.
    • 2018-05-09 CT - chest and upper abdomen
      • RCC with lung and mediastinal LNs metastasis, in regression compared with previous CT study.
    • 2018-02-13 CT - chest and upper abdomen
      • Metastatic mediastinal and left hilar LAPs and Lt Main bronchus with left lung atelectasis.
    • 2017-10-14 Renal Echo
      • Absence of left kidney with hypertrophy of right side kidney
      • History of RCC s/p left side nephrectomy
    • 2017-10-11 CT - chest and upper abdomen
      • suspected endobronchial CA in left main bronchus with obstructive pneumonitis.
    • 2017-08-03 MRI - kidney, adrenals
      • S/P left nephrectomy with residual minimal fatty infiltrates in left renal fossa.
      • GB stones.
    • 2017-05-06 CT - abdomen
      • S/P left nephrectomy with fluid density in left renal fossa, seroma, abscess or hematoma?
      • Thickening/edema of small bowel loops around surgical region.
    • 2017-03-24 CT - abdomen
      • Left renal tumor, suspected RCC, suspicious renal venous branch invasion. Cstage T3N0Mx.
    • 2017-03-22 Renal Echo
      • Left renal tumor was noted at Taipei CGMH
  • radiotherapy
    • 2022-03-02 ~ 2022-03-15 - 3000cGy/10 fractions (IMRT) to Rt iliac bone, palliative
    • 2020-03-27 ~ 2020-04-06 - 3000cGy/10 fractions (6 MV photon) to L5, & 3000cGy/10 fractions to Rt hip
    • 2018-08-16 ~ 2018-08-31 - 3600cGy/12 fractions (6 MV photon) to Rt humeral head
  • chemoimmunotherapy
    • 2022-03-17 ~ 2022-04-11 - everolimus
    • 2022-03-17 - denosumab
    • 2022-02-19 ~ 2022-02-26 - axitinib
    • 2018-03-02 ~ 2020-06-17 - axitinib
    • tried oral sunitinib, axitinib (Cheng Hsin General Hospital)

==========

2022-04-11

  • The patient was diagnosed with RCC with metastatic mediastinal LAPs, suspected RUL lung metastases, liver and bone metastases and is currently enrolled in hospice combined care (since 2022-03-11).
  • He is now taking everolimus (since 2022-03-17 s/p axitinib) and has tried denosumab to prevent pathological spontaneous fractures, as well as opioid analgesics to relieve pain.
  • Serum calcium 1.55mmol/L (normal 2.2 ~ 2.65) and magnesium 1.8mg/dL (normal 1.9 ~ 2.7) reported on 2022-04-10. In patients with hypomagnesemia, hypocalcemia is difficult to correct without first normalizing the serum magnesium concentration. The patient’s serum magnesium was just slight below normal range and currently treated with oral magnesium oxide and calcium carbonate without issues.
  • Urine bacteria (1+) were reported on 2022-04-10; since everolimus is also an immunosuppressive agent, some ABX might be considered to prevent an infection from worsening.

2022-03-18

  • The RCC patient with multiple bone metastases in progression (2022-02-23 CT), has been treated with axitinib and sunitinib.
  • If the conditions are covered by the national health insurance or a commercial insurance, or the patient is financially able to afford the medication, immunotherapy might also be considered as an add-on treatment.
  • Some regimens in which drug used in immunotherapy can be found, including but not limited to:
    • axitinib + pembrolizumab
    • cabozantinib + nivolumab
    • lenvatinib + pembrolizumab
    • ipilimumab + pembrolizumab
  • Hospice care is being considered by the patient and his family.
  • Caregivers have an urgent problem of controlling pain for patients at home that needs to be resolved. Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered.
  • The following interventions are available to treat metastatic bone cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
    • Epidural and selective nerve root block
    • Radiofrequency ablation and cryoablation
    • Vertebral augmentation
    • Intrathecal drug delivery
    • Spinal cord stimulation
    • Dorsal root ganglion stimulation

700815802

220411

{Recurrence nasopharyngeal carcinoma with skull base destruction and cranial nerve (V2, VI) invasion , liver metastasis and multiple lung metastases in progression.yT4N2M1,stageIVB}

[objective]

  • exam finding
    • 2022-03-24 Chest
      • Borderline cardiomegaly
      • Increased lung markings on both lower lung are noted.
      • Hypoinflation of both lung is noted.
    • 2022-02-19 CT - liver, spleen, biliary duct, pancreas
      • Progression of liver metastases.
      • Multiple lung metastases.
    • 2021-10-19 MRI - nasopharynx
      • NPC, s/p R/T with abnormal residual enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
      • Chronic bilateral mastoiditis and paranasal sinusitis, stationary.
    • 2021-09-25 CT - abdomen, pelvis
      • Liver metastasis with tumors regression (partial remission)
    • 2021-06-16 CT - liver, spleen, biliary duct, pancreas
      • Multiple metastases on both hepatic lobes show stable disease or progressive disease.
    • 2021-04-28 Nasopharyngoscopy
      • bulging tumor over NP, subside
      • NPC s/p CCRT with recur
    • 2021-04-22 SONO - abdomen
      • liver tumors, bil. propable metastases
      • suspected liver cyst, right
      • suspected right renal cyst
    • 2021-02-26 CT - abdomen, pelvis
      • Multiple metastases on both hepatic lobes show stable disease.
    • 2021-02-08 MRI - nasopharynx
      • C/W NPC s/p treatment with residual abnormal signal intensity at skull base, stationary as compared with MRI on 2020817.
    • 2021-02-01 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20200213, increased radiotracer uptake in skull base had been slightly less evident, probably indicating post-treatment inflammatory change. Please correlate with other imaging modalities to exclude the possibility of malignant local bone invasion.
      • Mildly and non-focally increased radiotracer uptake in lower L-spine and sacrum, degenerative spine diseases may show such a picture.
      • Some faint hot areas in maxilla and mandible, dental lesions may show such a picture.
      • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, manubriosternal joint, sacroiliac joints, and hips.
      • No definite evidence of distant osteoblastic skeletal metastasis by this bone scan.
    • 2021-01-05 GI bleeding embolization
      • Duodenal hemorrhage s/p TAE.
    • 2021-01-04 Esophagogastroduodenoscopy
      • Diagnosis
        • Reflux esophagitis LA classification grade A
        • Incomplete study of stomach and doudenum
        • Duodenal ulcers, 2nd portion, s/p hemostasis with injection, APC & hemoclipping
      • Suggestion
        • Transfer to ICU for intensive care and monitor
        • NPO with high dose PPI for at least 3 days
        • Angiography is suggested if active bleeding develops
    • 2020-11-17 CT - abdomen, pelvis
      • Liver metastsis, regression.
      • Liver cysts.
      • Right renal cyst.
    • 2020-10-12 Nasopharyngoscopy
      • bulging tumor over NP, subside
      • npc s/p ccrt with mets
    • 2020-09-22 Patho - colon biopsy
      • Rectum, biopsy - Nonspecific proctitis with superficial ulcer
    • 2020-09-18 Patho - stomach biopsy
      • Stomach, antrum, PW & LC side, biopsy - ulcer. No H.pylori present
    • 2020-08-17 MRI - nasopharynx
      • NPC, s/p R/T with abnormal residual enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
      • Chronic bilateral mastoiditis and paranasal sinusitis.
    • 2020-08-12 CT - liver, spleen, biliary duct, pancreas
      • Multiple metastases on both hepatic lobes.
    • 2020-08-04 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Metastatic non-keratinizing squamous carcinoma, consistent with nasopharynx primary
      • The secvtions show non-keratinizing squamous cell carcinoma, composed of nests of poorly differentiated neoplastic cells in fibrous stroma.
      • IHC, tumor cells reveal: CK7(-), CK20(-), p40 (+) and Hepa-1(weakly +). The finding is consistent with metastatic nasopharyngeal carcinoma.
    • 2020-07-29 CT - CTA, chest
      • no acute pulmonary embolism.
      • multiple HCC in both lobes.
    • 2020-05-07 SONO - abdomen
      • fatty liver, mild
      • liver tumors, bil. propable metastases
      • suspected liver cyst, left
      • suspected fatty infiltration of pancreas
      • suspected right renal cyst
      • s/p cholecystectomy
    • 2020-03-26 MRI - nasopharynx
      • NPC, s/p R/T with abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure, and clivus still visible, stationaryas compared with MRI 2019/11/26
      • Chronic mastoiditis and otitis media.
      • Thyroid goiter.
    • 2020-02-24 Nasopharyngoscopy
      • npc s/p ccrt with recur
    • 2020-02-13 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20180613, the hot spot in the skull base is less evident. Please correlate with other imaging modalities for further evaluation.
      • The previous hot spot in the suerolateral aspect of the left orbital area of the skull is less evident and the previous rib lesions disappeared, probably more benign in nature.
      • Suspected benign lesions in bilateral sternoclavicular junctions, shoulders, knees, and feet.
    • 2020-02-10 CT - abdomen
      • No interval change of liver lesions.
      • Right renal cyst (2.4cm).
    • 2019-11-26 MRI - Nasopharynx
      • NPC, s/p R/T with abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
      • Chronic bilateral mastoiditis.
    • 2019-10-18 CT - abdomen
      • Indication: NPC with liver Metastasis in S5 s/p RFA, for follow up
      • Impression: Prior CT identified metastasis in S5 S/P RFA shows complete response.
    • 2019-07-23 Echo for liver, gall bladder, pancreas, spleen
      • Hepatic tumor, probably metastatic tumor (S5-6)
      • Hepatic tumor, probably post RFA change (S8, according hx and CT)
      • Hepatic cyst
      • Postcholecystectomy
    • 2019-07-15 CT - abdomen
      • Liver tumors s/p RFA. suspected residual tumor in S6 of liver.
    • 2019-06-03 MRI - nasopharynx
      • Indication:
        • NPC, with skull base destruction and cranial nerve (V2, VI) invasion, cT4N2M0. s/p CCRT and adjuvant RT.
      • Impression:
        • NPC, s/p R/T with abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
        • Chronic Right mastoiditis.
    • 2019-05-21 Surgical pathology Level V
      • Liver, needle biopsy — Metastatic undifferentiated carcinoma.
    • 2019-05-21 SONO guide biopsy
      • Metastasis in S5 of the liver is suspected.
    • 2019-04-23 Echo for liver, gall bladder, pancreas, spleen
      • Diagnosis
        • Hepatic tumor, probably metastaic tumor
        • GB stone, multiple
        • Splenomegaly, mild
      • Suggestion
        • refer to medical ONC for further evaluation and treatment
    • 2019-04-11 CT - abdomen
      • A faint enhancing lesion (2.1cm, srs501, img19) in S5 of liver.
    • 2019-02-27 Whole body PET scan
      • No significantly increased FDG uptake in bilateral N-P regions and skull base was noted, indicating response to current therapy.
      • Glucose hypermetabolism in the left lobe of the thyroid gland, the nature is to be determined (functioning nodule, benign or malignant neoplasm, or others ?), suggesting biopsy for further investigation.
      • Glucose hypermetabolism in the right lobe of the liver and in a nodular lesion in the RLQ of abdomen, the nature is also to be determined (benign or malignancy/metastasis ?).
    • 2019-02-19 MRI - nasopharynx
      • NPC, s/p R/T with post R/T change abnormal enhancing soft-tissue at Rt skull base, pterygopalatine fissure and clivus, stationary.
      • Chronic Right mastoiditis.
    • 2018-12-11 SONO - abdomen
      • Fatty liver, mild
      • Liver cyst, left lobe
      • Gall stone
      • Renal cyst, left kidney
      • Splenomegaly
    • 2018-11-13 MRI - nasopharynx
      • NPC, s/p R/T with post R/T change abnormal enhancing soft-tissue at Rt pterygopalatine fissure and clivus, suggest F/U.
      • Right mastoiditis.
    • 2018-06-13 Tc-99m MDP whole body bone scan
      • A hot spot at the skull base, NPC with local bone involvement should be considered, suggesting F-18 FDG PET/CT scan for further investigation.
      • Three hot spots in the right 8th to 10th ribs, respectively, the nature is to be determined (post-traumatic change or other nature?). Please follow up bone scan in 3 months.
      • Suspected benign lesions in the left rib cage, bilateral sternoclavicular junctions, shoulders, knees, and feet.
    • 2018-06-12 MRI - nasopharynx
      • NPC T4N2Mx
      • Right mastoiditis.
    • 2018-05-28 Surgical pathology Level IV
      • Nasopahrynx, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
      • IHC stain: CK (+).
  • lab data
    • EBV
      • 2021-03-01 1236copies/mL (normal < 120)
      • 2019-11-11 <120
      • 2019-02-02 252
      • 2018-09-17 <120
  • surgical operation
    • 2021-01-07
      • Surgery
        • duodenal ulcer suture ligation
        • trucal vagotomy wth pyloroplasty
      • Finding
        • active duodenal 2nd portion ulcer bleeding
        • chronic DU with bulb deformity
  • radiotherapy
    • 2018-07-13 ~ 2018-08-23 - completed RT to the bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The NP tumor and LAPs: 70 Gy/ 35 fx.
  • chemotherapy
    • 2022-03-04 ~ undergoing - 5-Fu + Leucovorin
    • 2021-07-09 ~ 2021-12-03 - Doxorubicin
    • 2021-05-11 ~ 2021-06-07 - 5-Fu + Leucovorin
    • 2020-08-27 ~ 2020-12-22 - 5-Fu + Leucovorin

[assessment]

  • This is a patient with non-keratinizing nasopharyngeal carcinoma (2018-05-28 pathology).
  • According to medical images during the last 12 months (2021-04 and 2022-04), the primary lesions (s/p CCRT, now on FL) are generally stable, however, liver metastases (s/p RFA) appear to have developed.
  • Nivolumab might be an optional alternative for nonkeratinizing NPC that has previously been treated.

700174551

220408

{rectal cancer with liver mets s/p LAR and liver partial resection}

[objective]

  • exam finding

    • 2022-04-06 Abdominal sonography
      • post cholecystectomy
      • parenchymal liver disease
    • 2022-03-08 CT - abdomen, pelvis
      • Rectal cancer s/p operation. Wall thickening of proximal A-colon.
      • Mild regression of liver metastases.
    • 2021-12-08 CT - abdomen, pelvis
      • Metastasis 1.5 cm in S7 of the liver is highly suspected.
    • 2021-08-27 Patho - liver partial resection
      • pathologic diagnosis
        • Liver, S2-3, segmental hepatectomy — Metastatic rectal adenocarcinoma
        • Liver, S5, segmental hepatectomy — Metastatic rectal adenocarcinoma
        • Liver, S8, segmental hepatectomy — All specimen taken for section and no metastatic carcinoma present
        • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
      • microscopic examination
        • Diagnosis: Metastatic rectal adenoarcinoma x3
        • Histologic grade: Moderately differentiated
        • Tumor growth pattern: Infiltrating
        • Tumor pseudocapsule: Present
        • Tumor necrosis: Present (50%)
        • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.4 cm (S5)
        • Vascular invasion: Not identified
        • Perineural invasion: Not identified
        • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
        • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, mild lymphocytic portal inflammation, and mild fatty change (10%)
    • 2021-06-15 CT - abdomen, pelvis
      • rectal cancer s/p LAR and autosuture with liver mets.
      • the liver mets regressed.
    • 2021-02-18 Patho - colon segmental resection for tumor
      • pathologic diagnosis
        • Large intestine, rectum, robotic-assisted low anterior resection —- Adenocarcinoma, moderately differentiated
        • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (1/21)
        • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1a(if cM0), or pStage IVA, pT3N1a(if cM1a), Please correlate with the clinical presentation and image study
      • microscopic examination
        • Histology: adenocarcinoma
        • Histology Grade: moderately differentiated
        • Depth of invasion: mesocolic soft tissue
        • Angiolymphatic invasion: Present.
        • Perineural invasion: Present.
        • Discontinuous extramural tumor extension: Not identified.
        • Circumferential (radial) margin of rectum: Uninvolved, 16 mm from the margin
        • Lymph node metastasis, mesocolic: 1/21
        • Lymph node metastasis, IMA / SMA: not received
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN1a: One regional lymph node is positive
          • Distant Metastasis (pM): if cM0 or cM1a(CT finding)
        • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
        • S2021-02016 IHC: EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2021-02-08 CT - abdomen, pelvis
      • Imaging stage: T2N1bM1a stage IVA
    • 2021-02-05 Patho - colorectal polyp
      • Large intestine, rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      • IHC: EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2021-02-04 Colonoscopy
      • A mass was noted in the rectum, size 3cm, 10cm from anal verge, suspected malignancy.
    • 2020-09-01 Renal echo
      • parenchymal renal disease
  • lab data

    • 2021-03-08 NRAS/KRAS mutation not detected
  • surgical operation

    • 2021-08-26
      • surgery
        • S2-3 resection
        • S8 and S5 partial resection
        • LC
      • finding
        • S2-3 two hypoechoic tumor + 1.5cm in diameter suspected hypoechoic tumor 1.2cm at S8
        • superifcal small tumor at S5 near GB
        • echo didn’t find any tumor at right posterior segment
    • 2021-02-17
      • surgery
        • Robotic-assisted low anterior resection        
      • finding
        • Rectal cancer 43.52 cm at 10 cm from AV
  • chemoimmunotherapy

    • 2021-04-27 ~ undergoing - FOLFIRI + bevacizumab
    • 2021-03-12 ~ 2021-04-12 - FOLFIRI

[assessment]

  • The patient with rectal cancer and liver mets has received FOLFIRI since 2021-03-12 (plus bevacizumab since 2021-04-27) s/p LAR (2021-02-17) and liver partial resection (2021-08-26).
  • Available molecular review results include: pMMR, EGFR(+), NRAS/KRAS WT; no BRAF, HER2, NTRK results found.
  • Recent surveillance detected suspected mets in S7 (CT, 2021-12-08) and proximal A-colon wall thickening (CT, 2022-03-08), CEA fluctuates within a narrow range of 10 to 13 ng/mL since November 2021.
  • There is still some progression of the disease (albeit at a slower rate?)

700598345

220407

{Acute myeloblastic leukemia, not having achieved remission}

[objective]

  • exam finding
    • 2022-03-24 Patho - bone marrow biopsy
      • Bone marrow, iliac, (AML, S/P induction C/T and consolidation C/T x 2), biopsy - Normal cellularity.
      • IHC: CD117: <1 %; CD34: <1 %; MPO: 20-30%, CD61: 5-10%; CD71: 70-75% (of the nucleated cells).
      • Section shows piece(s) of bone marrow with 40% cellularity and M:E ratio of approximately 1:3. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • 2022-03-09 CT - lung/mediastinum/pleura
      • pulmonary infection or leukemic infiltration in both lungs.
    • 2021-12-14 Patho - bone marrow biopsy
      • Bone marrow, iliac bone, biopsy - Hypocellularity and no increase of blast
      • Hypocellularity for her age, 5-10%
      • Marked hypoplasia of all three lineages
      • No obviously increase of blast
    • 2021-11-29 Patho - bone marrow biopsy
      • Bone marrow, iliac bone, biopsy - Compatible with acute myeloid leukemia
      • Microscopically, the sections show a picture of acute myeloid leukemia, composed of hypercellular marrow (70-80%) with proliferative blasts about 30% of nucleated cells, which immunohistochemistry shows CD34(+), CD117(+) and MPO(+). Besides, hypoplasia of erythroid series and megakaryocytes highlights by CD61(+, megakaryocytes) and CD71(+, erythroid series) is also noted. Clinical and bone marrow smear correlation is advised.
  • lab data
    • 2022-03-18 P.jiroveci DNA-Sp undetectable
    • 2021-12-09 FLT3-D835 mutation undetectable
    • 2021-12-02 Aspiration
      • CD2 NA
      • CD3 0.39
      • CD4 NA
      • CD5 0.14
      • CD7 61.64
      • CD8 NA
      • CD10 1.15
      • CD11b 2.5
      • CD13 77.23
      • CD14 5.23
      • CD15 NA
      • CD16 2.28
      • CD19 1.14
      • CD19/kappa NA
      • CD19/Lambda NA
      • CD20 NA
      • CD23 NA
      • CD25 NA
      • CD33 99.86
      • CD34 92.71
      • CD38 NA
      • CD56 0.05
      • CD103 NA
      • CD117 83.82
      • CD138 NA
      • FMC7 NA
      • HLA-DR 95.7
      • MPO NA
      • TdT NA
  • chemotherapy
    • 2022-01-07 ~ undergoing - cytarabine (high dose Ara-C, HiDAc, 300mg/m2 IVD 3h Q12H D1,3,5 total 5 doses or 200mg/m2 3h Q12H D1-4 total 8 doses) + daunorubicin (45mg/m2 IV D1-3)
    • 2021-12-02 - idarubicin (45-80mg/m2 d1-3) + cytarabine (100-200mg/m2 d1-7)
  • consultation
    • 2021-12-02 Dr. YaoRen Xu
      • Q
        • This 40 year-old female patient who has history of childhood epilepsy under medication was admitted via the OPD due to leukocytosis with anemia and thrombocytopenia. The PB smear showed increase blast cells (40-60%). Acute leukemia is considered. She was admitted for bone marrow biopsy and AML was confirmed. We will start chemotherapy with regimen of Idarubicin + Cytarabine - 3 + 7 days.
        • She is unmarried, G0P0 and no GYN history. For prevention of excessive bleeding, we need to halt her menstrual cycle.
      • A
        • consider to halt menstrual cycle due to thrombocytopenia
        • no active GYN problems
        • Danazol 200ml 1# BID PO may be considered, no more than 6 months, can be administered during chemotherapy course.

==========

2022-04-07

  • The patient with AML (2021-11-29 bone marrow biopsy pathology) without the FLT3-D835 mutation (2021-12-09 undetectable) was treated with high dose cytarabine + daunorubicin starting on 2022-01-07, following idarubicin + cytarabine (3+7) in December 2021.
  • The last two consecutive bone marrow biopsy pathology (2021-12-14 and 2022-03-24) showed no obviously increase of blast and normal cellularity. So far, so good.
  • There were no other obvious abnormalities found except an elevated level of uric acid of 7.6 mg/dL reported on 2022-04-06, which might be controlled with febuxostat or benzbromarone.

2022-03-11

[compatibility]

The combination of calcium gluconate, magnesium sulfate, and potassium chloride in 0.9% sodium chloride normal saline is compatible.

2022-01-10

Lab data reported on 2022-01-10

  • RBC 3.44*10^6/uL
  • HGB 9.4g/dL

Danol (Danazol) androgen is prescribed to pause menses to maintain RBC, HGB levels in the setting of chemotherapy.

700728977

220407

{rectal cancer cT2N1bM0 stage IIIA}

[subjective]

  • 2021-07-12 having anal fresh bleeding on and off prior to visiting OPD.
  • family history: two younger brothers died because of colon cancer.

[objective]

  • exam finding
    • 2021-11-04 Patho - colon segmental resection for tumor
      • Large intestine, rectum, low anterior resection —- No residual viable tumor, s/p neoadjuvant CCRT
      • Resection margins: free
      • Lymph node, mesocolic, dissection - Negative for malignancy (0/17)
      • Lymph node, IMA / SMA, dissection - Not received
      • AJCC 8th edition Pathology stage: ypT0N0(if cM0)
    • 2021-10-20 Patho - colon biopsy
      • Large intestine, rectum, biopsy - non-specific colitis with fibrosis
    • 2021-10-19 CT - abdomen, pelvis
      • Compatible with rectal cancer s/p CCRT with swelling of the sigmoid colon.
    • 2021-07-20 CT - lung/mediastinum/pleura
      • combined emphysema and pulmonary fibrosis.
      • old RUL TB change.
    • 2021-07-16 Patho - colorectal polyp
      • Rectum, 8 cm from anal verge, biopsy — Adenocarcinoma
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2021-07-15 CT - abdomen, pelvis
      • for colorectal carcinoma T2N1bM0 IIIA
    • 2021-07-15 Colonoscopy
      • suspected rectal malignancy, 8cm from anal verge, s/p biopsy
      • diverticula, sigmoid colon, with lumen narrowing
      • mixed hemorrhoid
    • 2020-11-24 CT - brain
      • Brain atrophy
      • Atherosclerosis of vertebral arteries
  • surgical operation
    • 2021-11-03
      • Low anterior resection
        • Adenocarcinoma of rectum, cT2N1bM0, Stage IIIA s/p neoadjuvant CCRT
        • Anastomosis by CDH 29#, TISSEL 4ml covered on anastomosis site
        • TA contour for low anterior resection
        • Protective ileostomy was created on RLQ area
  • radiotherapy
    • 2021-07-28 ~ 2021-09-07 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15MV photon) of the rectal tumor area. (pre-op CCRT)
  • chemotherapy
    • 2021-12-14 ~ undergoing - FOLFOX
    • 2021-08-03 - 5-Fu + leucovorin (pre-op CCRT)

==========

2022-04-07

  • The patient was diagnosed with T2N1bM0 stage IIIA rectal cancer and had LAR in Nov 2021 following pre-op CCRT during the 3rd quarter of that year; he is currently undergoing adjuvant FOLFOX regimen since Dec 2021.
  • A colon segmental resection pathology on 2021-11-04 revealed no residual viable tumor and evaluated the disease as ypT0N0 (if cM0).
  • As of 2022-03-29, the laboratory data showed normal liver and kidney function as well as slightly lower blood cell counts, which should not affect the chemotherapy course.
  • HBV is managed with Baraclude (entecavir) currently.

2021-08-05

[initial presentation]

  • 2021-07-12 having anal fresh bleeding on and off prior to visiting OPD.
  • family history: two younger brothers died because of colon cancer.

[definite diagnosis]

  • 2021-07-15 colonoscopy:
    • suspected rectal malignancy, 8cm from anal verge.
    • diverticula, sigmoid colon, with lumen narrowing.
    • mixed hemorrhoid
  • 2021-07-16 patho - colorectal polyp
    • adenocarcinoma
    • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+)

[disease extent]

  • 2021-07-15 CT - whole adbomen, pelvis:
    • imaging stage: cT2N1bM0, IIIA

[treatment & plan]

  • pre-Op CCRT then Op
    • radio
      • 4500cGy/25frac for pelvic
        • 900cGy/5frac from 2021-08-04 to 2021-08-06
      • 5040cGy/28frac for rectal tumor bed
    • chemo
      • 5-Fu + leucovorin from 2021-08-04

[effect & side effect]

  • CCRT just started, to wait and see.
  • adjuvant chemo with cetuximab/panitumumab (EGFR+) might be indicated after resection operation.
    • no RAS, BRAF, or other immune checkpoint biomarkers tested found in charts yet.

[ongoing problem]

  • HBV
    • 2021-07-23 lab data
      • Anti-HBc Reactive
      • Anti-HBs 31.38mIU/mL
    • medication
      • baraclude (entecavir 0.5mg) QDAC
  • combined pulmonary fibrosis and emphysema
    • 2021-07-20 CT lung/mediastinum/pleura found

[assessment]

  • CCRT just kicked off and HBV is managed by entecavir, no medication issue observed.

700713215

220406

{hepatic failure, cirrhosis of liver, hepatorenal syndrome, esophageal varices, gastric varices, ascites, type 2 diabetes ellitus, hyperlipidemia, anemia}

  • All the oral drugs can be administered with nasogastric tube.
  • For the patient with hepatorenal syndrome, albumin (lower serum reading 2.8 g/dL reported on 2022-04-06) might be an option to combine with terlipressin (currently prescribed).

700733699

220406

[objective]

  • diagnosis
    • liver cell carcinoma
    • recurrence hepatocellular carcinoma with lung and bone metastasis, stage IV
    • hepatitis B virus related liver cirrhosis, child A
    • essential (primary) hepertension
    • type 2 diabetes mellitus without complications
  • exam finding
    • 2022-03-07 CT - liver, spleen, biliary duct, pancreas
      • HCC s/p right hepatic lobectomy and RFA at S2, S3 and S4.
      • Bilateral Lung meta, stationary.
      • Bone meta. Suggest bone scan study.
    • 2021-11-24 CT - liver, spleen, biliary duct, pancreas
      • Cholangiocarcinoma at S3 liver is highly suspected.
      • The differential diagnosis include metastasis (colon cancer?) and atypical HCC. Please correlate with tumor marker and MRI. Biopsy is indicated.
      • Two metastases in S3 are suspected.
    • 2021-11-23 Tc-99m MDP whole body bone scan with SPECT
      • In comparison with the previous study on 20210720, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
      • Suspected benign lesions in bilateral shoulders.
  • chemmoimmunotherapy
    • 2020-03 ~ undergoing - lenvatinib
    • 2020-01-17 ~ 2020-12-22 - nivolumab
    • 2019-09 ~ 2019-12 - sorafenib

[assessment]

  • This patient with advanced HCC (lung and bone mets) has been treated with sorafenib (Sept to Dec in 2019), Nivolumab (in 2020) and Lenvatinib (since March 2020), he refuses to be resuscitated and has been referred to the hospice ward waiting list.

700769250

220331

{ovary cancer s/p oophrocystectomy}

[objective]

  • exam finding
    • 2022-02-15 Patho - uterus
      • pathologic diagnosis
        • Ovary, right, debulking surgery (s/p oophorcystectomy) - No residual tumor
        • Ovary, left, debulking surgery - Negative for malignancy
        • Fallopian tube, bilateral, debulking surgery - Negative for malignancy
        • Uterus, corpus,debulking surgery - Adenocarcinoma, seeding
        • Uterus, cervix, debulking surgery - Negative for malignancy
        • Omentume, debulking surgery- - Peritonitis
        • Labeled “utreosaroligment” - Negative for malignancy
        • Labeled “rectum” - Negative for malignancy
        • Labeled “right abdominal wall” - Negative for malignancy
        • AJCC 8th edition Pathology stage: pT2aNO(if cM0); FIGO IIA; AJCC stage IIA
      • microscopic examination
        • Histologic type: Adenocarcinoma, mixed endometrioid type and mucinous type
        • Histologic grade: grade 1
        • IHC: CK(+), Calretinin(focal+), CD68(+), PAX8(-); Reference: S2022-01793
    • 2022-02-11 CT - pelvis
      • An enlarged nodes in left pelvic side wall measuring 2.3 cm in size is noted.
    • 2022-02-04 Patho - ovary biopsy, wedge resection
      • Diagnosis:
        • Ovary, right, laparoscopic oophorocystectomy —- Adenocarcinoma, mixed endometrioid type and mucinous type, grade 1
          • IHC stains: WT( focal +), PAX-8 (-), p53 (wild type), Napsin-A (-), ER (-), PR (-).
          • pT1c2 pNx (if cM0); FIGO stage: IC2, at least.
      • Gross description:
        • Tumor Site: Right ovary
        • Ovarian Surface Involvement - Absent
        • Fallopian Tube Surface Involvement - no tissue submitted.
      • Microscopic Description:
        • Histologic Type: Mixed epithelial carcinoma: endometrioid grade 1 (60%) and mucinous grade 1 (40%).
        • Histologic Grade - WHO Grading System-G1: Well differentiated
        • IHC: WT( focal +), PAX-8 (-), p53 (wild type), Napsin-A (-), ER (-), PR (-).
    • 2022-01-31 CT - abdomen, pelvis
      • A lobulated right adnexal mass (9.0x6.8x10.2cm). Suspect TOA, ovarian torsion, or ovarian cystic tumor.
  • surgical operation
    • 2022-02-14
      • Excision of abdominal wall tumor
      • Excision of greater omentum and rectal serosa tumor
      • IOUS (intraoperative ultrasound)
    • 2022-01-31
      • ROV teratoma with rupture
      • pelvic adhesion
      • Laparoscopic oophorocystectomy + pelvic adhesionlysis       
  • chemotherapy
    • 2022-03-09, -03-30 - paclitaxel + carboplatin
  • underlying disease
    • chronic viral hepatitis B without delta-agent

[assessment]

  • This patient was diagnosed with ovarian adenocarcinoma, mixed endometrioid and mucinous type in early 2022 s/p oophrcystectomy (2022-01-31) and excision of abdominal wall tumor and greater omentum and rectal serosa tumor (2022-02-14).
  • paclitaxel + carboplatin is a preferred regimen for both endometrioid and mucinous ovarian cancers, and the patient has been receiving this regimen since 2022-03-09.
  • According to CBC results on 2022-03-29, there was a slight decrease in readings, not expected to affect chemotherapy.
  • HBV is managed with Baraclude (entecavir). No issue with current medication.

700814298

220330

[objective]

  • diagnosis
    • Pancreatic cancer, T3N1M1 (M1 diagnosed by CT), stage IV, tail, status post endoscopic ultrasound-guided fine-needle biopsy on 2021-10-07
  • exam finding
    • 2022-03-21 CT - abdomen, pelvis
      • Pancreatic cancer with liver mets and adrenal mets. In progression.
      • Paraaortic lymphadenopathy, stable
      • Diffuse lung consoliations. Nature to be determined.
      • Air pockets inside the urinary bladder, suspected emphysematous cystitis.
    • 2022-01-07 CT - brain
      • Old lacunar infarcts.
      • Encephalomalacic change in left temporal lobe.
      • Brain atrophy.
    • 2021-12-07 CT - abdomen, pelvis
      • Pancreatic tail cancer with liver mets. The primary tumor is decreased in size but the liver mets progressed.
      • Paraaortic lymphadenopathy, in regression.
      • LEFT LOWER LOBE consolidation.
    • 2021-10-07 Patho - pancreas biopsy
      • Pancreas, EUS-FNB - adenocarcinoma, moderately differentiated
      • Sections show pancreas with neoplastic glandular cells infiltrating in fibrous stroma.
    • 2021-10-07 Needle aspiration cytology
      • Smears show necrotic debris and clusters of atypical, hyperchromatic cells. Malignancy is favored.
    • 2021-10-04 CT - abdomen, pelvis
      • suspected pancreas CA with splenic vessels and stomach invasions
      • Liver and para-aortic lymph node metastases
    • 2018-07-23 MRA - brain
      • recent ischemic of left MCA territory due to severe stenosis in distal M1 an M2 of left MCA.
      • Brain atrophy. Multiple lacunar infarcts, deep cerebral hemisphere and cerebellum.
      • Bilateral subcortical and periventricular white matter change (leukoaraiosis).
    • 2018-07-20 CT - brain
      • Brain atrophy and lacunar infarcts.
  • chemotherapy
    • 2021-10-26 ~ undergoing - gemcitabine + nab-paclitaxel
  • past history
    • Gout arthritis for 40+ years
    • CVA with right side hemiparesis and motor aphasia since 2018-07

[assessment]

  • Patient presents with stage IV T3N1M1 pancreatic cancer with paraaortic LAP, liver mets, and adrenal mets.
  • Fusions (ALK, NRG1, NTRK, ROS1), mutations (BRAF, BRCA1/2, HER2, KRAS, PALB2), and MMR status were not found in HIS5.
  • FOLFIRINOX or gemcitabine + nab-paclitaxel would be preferred regimens. The patient has been receiving the latter since late October 2021.
  • This patient has just been arranged for hospice combined care on 2022-03-29.
  • No issue with current medication.

700799013

220329

[objective]

  • exam finding
    • 2022-02-25 CT - lung/mediastinum/pleura
      • Consolidation over both lungs. Pneumonia is favored.
      • Bilateral pleural effusion
    • 2022-01-11 Patho - omentum biopsy
      • Tissue, labeled LUQ omentum, CT-guide biopsy - adenocarcinoma, seeding
      • IHC: CDX-2(+), CK7(-), CK20(-). The tumor is compatible with GI tract origin.
      • Microscopically, it shows adenocarcinoma composed of irregular neoplastic glands with infiltrative growth pattern, tumor necrosis and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • 2021-11-24 CT - abdomen, pelvis
      • One Metastasis in LUQ omentum S/P C/T show partial response.
      • Two metastases in RLQ mesentery, and left lower pelvis (with urinary bladder invasion) S/P C/T show stable disease.
    • 2021-08-13 CT - abdomen, pelvis
      • Three Metastases 3.6 x 2.6 cm in the LUQ omentum area, 1.3 x 0.7 cm in RLQ mesentery, and 3.2 cm in left lower pelvis (with urinary bladder invasion) are noted.
      • Intrapulmonary lymph node in LLL of the lung is suspected and it shows stable in size and feature as compared with prior CT.
    • 2021-04-28 Whole body PET scan
      • Glucose-hypermetabolism in the soft tissue in the LUQ of abdomen, lower pelvis, and RLQ of abdomen, probably tumor recurrence.
      • Glucose-hypermetabolic lesions in the right shoulder and right elbow, probably post-traumatic change.
      • Increased FDG uptake in bilateral pulmonary hilar region, probably reactive nodes or physiological uptake of FDG.
      • Colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2021-04-20 CT - abdomen, pelvis
      • Some infiltration at right anterior abdominal wall is found, regional inflammation is considered
      • No evidence of soft tissue mass at pancreas.
    • 2021-01-18 CT - abdomen, pelvis
      • R-S colon cancer s/p operation. Some LNs at mediastinum and bil. inguinal regions.
      • Stationary condition and lung nodules.
    • 2021-11-19 Patho - colon segmental resection for tumor
      • diagnosis
        • Tumor, rectosigmoid, left hemicolectomy — Residual mucinous adenocarcinoma
        • Bilateral cutting ends, ditto — Free of tumor invasion
        • Lymph node, mesocolic, dissection — Free of tumor metastasis (0/18) with acellular mucin deposit (7/18)
        • Pelvic lesion, frozen section — Acellular mucin, compatible with tumor regression
        • AJCC pathologic stage — ypT3N0 (if cM0), stage IIA
    • 2020-10-05 CT - abdomen, pelvis
      • S-colon cancer as described (mild regression). T4bN2bM1a (IVa).
    • 2020-07-02 CT - abdomen, pelvis
      • S-colon cancer T4bN2bM1a (IVa).
    • 2020-06-30 Patho - colon biopsy
      • Sigmoid colon, 20 cm from anal verge, biopsy — Adenocarcinoma
      • IHC: EGFR(+), MLH1(-), PMS2(-), MSH2(+), and MSH6(+).
      • Comment: The tumor cells show loss of expression of the mismatch repair proteins MLH1 and PMS2. This pattern is likely to be sporadic (MLH1 promoter hypermethylation), although it is possible due to Lynch or related syndromes.
    • 2020-06-30 Patho - colorectal polyp
      • Rectum, 10 cm from anal verge, polypectomy — Adenocarcinoma in high-grade tubulovillous adenoma
      • The sections show adeocarcinoma in tubulovillous adenoma, composed of rectal mucosal tissue with atypical glands lined by pseudostratified, high-grade dysplastic columnar cells, in tubular, cribriform and villous arrangement. Focal desmoplastic stromal reaction is present.
  • surgical operation
    • 2021-03-11 Closure of T-loop colostomy
    • 2020-11-18 Exp. Lap with sigmoidectomy
    • 2020-07-06 T-loop colostomy
  • radiotherapy
    • 2020-07-22 ~ 2020-08-31 - 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the tumor bed area.
  • chemotherapy
    • 2021-06-11 ~ 2022-02-23 - FOLFOX + bevacizumab
    • 2020-07-16 ~ 2021-05-24 - FOLFIRI

701342376

220329

[objective]

  • exam finding
    • 2022-03-28 Colonoscopy
      • colon diverticulum, cecum, ascending colon
    • 2022-03-08 CT - abdomen, pelvis
      • S/P gastrectomy, splenectomy and pancreas operation. Fat stranding of upper peritoneal cavity.
    • 2021-10-28 Patho - small intestine resction (not tumor)
      • Small intestine, distal ileum, segmental resection - Consistent with Meckel diverticulum
      • Sections show ileal tissue with a diverticulum lined by gastric mucosal tissue. The morphology is consistent with Meckel diverticulum.
    • 2021-10-28 Patho - stomach subtotal/total (tumor)
      • pathologic diagnosis
        • Stomach, lesser curvature, total gastrectomy - Adenocarcinoma, moderately differentiated
        • Esophagus, total gastrectomy - Adenocarcinoma, by direct invasion with negative resection margin
        • Duodenum, total gastrectomy - Negative for malignancy
        • Liver, left lateral segment, segmentectomy - Negative for malignancy - Acute suppurative inflammation
        • Pancreas, distal, distal pancreatectomy - Negative for malignancy
        • Spleen, splenectomy - Negative for malignancy
        • Omentum, omentectomy - Negative for malignancy
        • Liver, caudate lobe, specimen B, resection - Negative for malignancy - Acute suppurative inflammation
        • Proximal esophagus, specimen C, resection - Negative for malignancy
        • Margin: free
        • Lymph node, lesser curvature, dissection - Negative for malignancy (0/8)
        • Lymph node, greater curvature, dissection - Negative for malignancy (0/14)
        • Lymph node, peri-pancreatic, dissection - Negative for malignancy (0/12)
        • AJCC 8th edition pT4aN0 (if cM0) pStage IIB,
        • F2021-423: Esophagus, resection margin, excision - Negative for malignancy
      • microscopic examnation
        • Histologic Type: Lauren classification of adenocarcinoma: Intestinal (tubular) type; The immunohistochemical stain Her-2/neu (Ab) is negative.
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades esophagus, the serosa (visceral peritoneum) and attached to the liver and pancreas capsule. No direct invasion in the liver and pancreas parenchyma is found. The subserosal liver parenchyma reveals acute suppurative inflammation. The immunohistocehmical stain of CK reveals no invasive tumor. The spleen, duodenum and omentum are free of tumor.
        • Additional Pathologic Findings
          • Intestinal metaplasia: absent
          • Low-grade dysplasia: absent
          • High-grade dysplasia: present
          • Helicobacter pylori-type gastritis
          • Autoimmune atrophic chronic gastritis: absent
          • Polyp(s): absent
  • surgical operation
    • 2021-10-27
      • Total gastrectomy with D2+ LN dissection
        • En-block left lateral segmentectomy with caudate loberesection with distal pancreatectomy with splenectomy
      • Distalsmallbowel segmental resection with anastomsois
  • radiotherapy
    • 2021-12-02 ~ 2021-12-06 - 540cGy/3 fractions (15 MV photon) to anastomosis and regional lymphatics
  • chemotherapy
    • 2022-01-24, -02-07, -02-22, -03-09, -03-28 - FOLFOX
    • 2021-12-08, -12-13, -12-20, -12-27, 2022-01-03 - 5-FU

[assessment]

  • gastric cancer pT4aN0 cM0 stage IIB s/p gastrectomy with D2+ LN dissection (2021-10-27) followed by post-Op CCRT (5-FU, early Dec 2021 to early Jan 2022) and adjuvant chemotherapy (FOLFOX, since late Jan 2022).
  • tumor pathology (2021-10-28) showed Her-2/neu (Ab) negative. no MSI/MMR, PD-L1 results found in HIS5
  • patients who have undergone primary D2 lymph node dissection are preferred to receive [capecitabine + oxaliplatin] and [fluorouracil + oxaliplatin], the latter is what the patient is getting now.
  • no adverse reaction found in nursing note for now during this hospital stay. no issue with current medication.

700070771

220325

[objective]

  • exam finding
    • 2022-02-12 CT - abdomen, pelvis
      • S/P liver and colon operation. No evidence of tumor recurrence.
    • 2022-02-07 SONO - abdomen
      • Post-op at right lobe liver. Calcified spot in the liver.
      • Right renal cyst.
      • Left renal stone.
    • 2011-11-04 CT - abdomen, pelvis
      • S/P liver and colon operation. Some fluid and air collection at right subphrenic region. Bil. pleural effusion with adjacent lung collapse.
    • 2021-10-29 Patho - liver partial resection
      • Liver, S6-7, segmental hepatectomy — Metastatic adenocarcinoma, consistent with colonic primary
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • 2021-09-22 CT - abdomen, pelvis
      • S/P right hemicolectomy. There is no evidence of tumor recurrence.
      • Two metastasis in S7 and S4 S/P C/T show partial response.
      • A newly-developed metastasis or flow artifact 0.5 cm in S6 liver is suspected.
    • 2021-05-20 NRAS/KRAS, BRAF not detected
    • 2021-05-17 MRI - liver, spleen
      • Two poor enhancing tumors (0.4cm, 2.6cm) in S8 of liver suspected metastases.
    • 2021-04-28 Patho - colon segmental resection for tumor
      • Pathologic diagnosis
        • Tumor, ascending colon, SILS R’t hemicolectomy — Adenocarcinoma
        • Resection margins, bilateral, ditto — Free from tumor invasion
        • Lymph node, mesocolic, dissection — Free from tumor metastasis (0/23)
        • Appendix, excision — Fecalith and free from tumor
        • AJCC pathologic stage — pT3N0, cM1a, compatible with stage IVA
      • Microscopic examination
        • Histology: adenocarcinoma
        • Histology Grade: G2: moderately differentiated
        • Depth of invasion: pericolonic fat
        • Angiolymphatic invasion: Present
        • Perineural invasion: Present
        • Discontinuous extramural tumor extension: NOT present
        • Circumferential (radial) margin of rectosigmoid: NOT involved
        • Lymph node metastasis, mesocolic: free from tumor metastasis (0/23)
        • Lymph node metastasis, IMA / SMA: N/A
        • Extranodal involvement: N/A
        • Pathological TNM Stage: pT3N0, but cM1a (liver meta), compatible with stage IVA
        • Type of polyp in which invasive carcinoma arose: N/A
        • Additional pathologic findings: focal necrosis and abscess
        • TNM descriptors: N/A
        • Tumor regression grading S/P CCRT: N/A
    • 2021-04-22 Whole body PET scan
      • Glucose hypermetabolism in the proxinal portion of the ascending colon and some adjacent lymph nodes, compatible with primary colon malignancy with some adjacent lymph node metastases.
      • A glucose hypermetabolic lesion in the segment 7 of the liver. A metastatic lesion may show this picture.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
    • 2021-04-19 CT - abdomen, pelvis
      • T3N2aM1a, stage IVA
    • 2021-04-16 Patho - colorectal polyp
      • Colon, ascending, biopsy — Adenocarcinoma.
      • IHC: EGFR(focal +); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
  • surgical operation
    • 2021-10-28 laparoscope S6-7 resection
      • solid tumor at S7
      • suspected small nodule at S6.
    • 2021-04-28 SILS Right-hemicolectomy
      • Adenocarcinoma of ascending colon, cT3N2aM1a (liver mets) stage IVa
      • Huge tumor with tissue edema suspecting as T4 lesion.
  • chemoimmunotherapy
    • 2021-06 ~ ongoing - FOLFIRI plus bevacizumab since
  • initial presentation
    • unintentional body weight loss 6 kgs in half year before diagnosed with cancer.
    • exertional dyspnea and intermittent right abdomen pain were noted without bowel habit change.
    • iOFBT(+)
  • underlying disease
    • type 2 diabetes
    • chronic hepatitis B

[assessment]

  • Patient with colon cancer with liver mets after SILS right hemicolectomy (2021-04-28) and liver S6/S7 resection (2021-10-28) is receiving FOLFIRI plus bevacizumab since June 2021. Recent CT (2022-02-12) and SONO (2022-02-07) have revealed no signs of recurrence.
  • Lab results reported on 2022-03-15 indicated no abnormality in liver or kidney functions, but a slight pancytopenia was detected. The lower blood counts should not affect the application of chemoimmunotherapy during this hospital stay.
  • Chronic hepatitis B and type 2 diabetes are managed with corresponding drugs.
  • No issue with current medication.

700464889

220325

{hypopharyngeal and supraglottic cancer, cT4bN2b cM0, stage IV with recurrent lung mets, progression of mets pulmonary lesions and mediastinal/hilar LAP}

[objective]

  • exam finding
    • 2022-03-10 Laryngoscopy
      • right hypopharyngeal cancer s/p induction chemotherapy + CCRT in 2016
      • lung mets proved in 2018-11, no local recurrence found according to PE and fiber
    • 2022-02-15 CT - lung/mediastinum/pleura
      • progression of metastatic pulmonary lesions and distant metastatic LAP as compared with previous CT on 20210823.
    • 2022-01-06 Laryngoscopy
      • right hypopharyngeal cancer s/p induction chemotherapy + CCRT in 2016
      • lung mets proved in 2018-11, no local recurrence found according to PE and fiber
    • 2021-11-30 Nasopharyngoscopy
      • saliva cumulation at hypopharynx and rt. piriform sinus
    • 2021-10-07 Laryngoscopy
      • right hypopharyngeal cancer s/p induction chemotherapy + CCRT in 2016
    • 2021-08-23 CT - lung/mediastinum/pleura
      • progression of metastatic pulmonary lesions and mediastinal and hilar LAP as compared with previous CT on 20210216.
    • 2021-05-14 MRI - Larynx
      • Post-treatment change at hypopharynx and larynx, without evidence of recurrence. Less edema as compared with previous MRI on 20181107.
    • 2021-05-11 SONO - abdomen
      • Few gallstones and the size < 1.15 cm.
      • Two renal cyst 2.37 cm in left lower pole and 0.91 cm in right middle pole are noted.
    • 2021-02-16 CT - lung/mediastinum/pleura
      • stationary of metastatic pulmonary lesions and progression of mediastinal and hilar LAP as compared with previous CT on 20200827.
    • 2020-11-17 SONO - abdomen
      • Few gallstones and the size < 0.68 cm.
      • Two renal cyst 1.57 cm in left lower pole and 1 cm in right middle pole are noted.
    • 2020-08-27 CT - lung/mediastinum/pleura
      • right upper lobe, left lingula lobe and right lower lobe lung mets, stable.
    • 2020-06-02 SONO - abdomen
      • Few gallstones and the size < 0.68 cm.
      • A renal cyst measuring 1.38 cm in left lower pole is noted.
    • 2020-03-10 CT -lung/mediastinum/pleura
      • metastatic tumors in bilateral lungs and medastinal and hilar lymphadenopathy, stationary as compared with previous CT study on 20191216.
    • 2019-12-16 CT
      • metastatic tumors in bilateral lungs and medastinal and hilar lymphadenopathy, in regression as compared with previous CT study on 20190916.
    • 2019-09-16 CT
      • metastatic tumors in bilateral lungs and medastinal and hilar lymphadenopathy, in regression as compared with previous CT study on 20190717.
    • 2019-07-17 CT
      • diffsue lung metastatic lesions and mediastinal lymphadenopathy, stable.
    • 2019-06-22 CT
      • metastatic tumors at bilateral lungs and medastinal and hilar lymphadenopathy, in progression as compared with previous CT study.
    • 2019-04-19 CT
      • pulmonary necrotic metastatic tumors at bilateral lungs and medastinal lymphadenopathy, in progression.
    • 2019-01-25 CT
      • compatible with hypopharyngeal cancer with lung mets. in regression.
    • 2018-11-07 MRI - Larynx
      • Post-RT changes at hypopharynx and larynx, without evidence of recurrence. Stationary as compared with MRI on 20180524.
    • 2018-11-07 Surgical pathology Level IV
      • Malignant hypopharynx neoplasm, pyriform sinus
      • Lung, side?, needle biopsy - squamous cell carcinoma, moderately differentiated, origin?
      • IHC: p40(+), TTF-1(focal weak positive), and CD56(focal weak positive). The results are in favor of squamous cell carcinoma.
      • Please correlate with the clinical presentation to differentiate primary or metastatic tumor.
    • 2018-11-06 Surgical pathology Level IV
      • Malignant hypopharynx neoplasm, pyriform sinus
      • Lung, side?, bronchoscopic biopsy - squamous cell carcinoma, moderately differentiated, origin?
      • IHC: p40(+), TTF-1(focal weak positive), and CD56(focal weak positive). The results are in favor of squamous cell carcinoma.
      • Please correlate with the clinical presentation to differentiate primary or metastatic tumor.
    • 2018-10-30 CT
      • hypopharynx cancer s/p RT s/p CT with lung and mediastinal-hilum LNs metastasis.
    • 2018-05-24 MRI - nasopharynx
      • Post R/T and C/T change in right pyriform sinus and adjacent hypopharynx, stationary.
    • 2017-11-28 MRI - nasopharynx
      • Post R/T and C/T change in right pyriform sinus and adjacent hypopharynx, seems stationary.
    • 2017-05-26 MRI - larynx
      • Right hypopharynx CA, post CT and R/T, stationary in size of abnormal soft-tissue combined more prominent post R/T change as compared with MRI on 20161121.
    • No earlier data available before 2017.
  • Chemoimmunotherapy
    • 2022-02-23, -03-24 - 5-FU + cisplatin + gemcitabine + nivolumab
    • 2021-09-10, -10-04, -11-01, -11-30, -12-27, 2022-01-17 - 5-FU + cisplatin + docetaxel + cetuximab

[assessment]

  • On CT images taken from the second half of 2019 through 2020, metastatic lesions in bilateral lungs, mediastinal and hilar lymphadenopathy remained stationary. However, on 2021-02-16 CT images, progression of mediastinal and hilar LAP was observed, then on 2021-08-23 and 2022-02-15 CT images, metastatic pulmonary lesions and distant metastatic LAP were observed.
  • From September 2021 to January 2022, the patient was treated with chemoimmunotherapy comprising 5-FU + cisplatin + docetaxel + cetuximab, followed by 5-FU + cisplatin + gemcitabine + nivolumab from February 2022 onwards.
  • The new regimen has been administered to the patient for the second time during this hospitalization, and it will take time for the responses to be confirmed.
  • The patient’s low serum magnesium reading on 2022-03-24 was treated with MgSO4 IVD QD.

700542356

220325

  • Patient was transferred from Cardinal Tien Hospital with a diagnosis of suspected MDS and urinary tract infection. Our emergency room did not note any obvious signs of discomfort, such as fever, chills, chest pain, dyspnea, or abdominal pain.
  • The following laboratory results were obtained on 2022-02-24: CRP 4.84 mg/dL, serum glucose 454 mg/dL, WBC 1040/uL, HGB 7.4 g/dL, PLT 3000/uL, NT-proBNP 5006 pg/mL, urine OB 3+, urine bacteria 1+, APTT 38 sec.
  • The blood culture result is not out yet. Symptomatic treatment is being provided to the patient currently. No issue is identified with the current medication.

700372070

220322

  • exam findings
    • 2022-01-28 CT
      • suspected lower third esophageal wall thickening. stable.
    • 2021-09-24 CT
      • borderline wall thickening at lower third esophagus is found.
    • 2021-09-24 Esophagogastroduodenoscopy
      • gastric intestinal metaplasia, antrum
    • 2021-09-09 Patho
      • Diagnosis
        • Lung, left lower lobe, history of hypopharyngeal and eosphaeal carcinomas, s/p CT and RT, now VATS lobectomy (S2021-12142A) with biopsy for forzen section (F2021-348FS) - squamous cell carcinomas x2, favor metastatic.
        • IHC: CK5/6(+), p40(+), Napsin-A(-), TTF-1(-), CD56(-).
        • pM1 pStage: IVC.
      • Microscopic Description
        • Tumor Focality - Separate tumor nodules of same histopathologic type in same lobe
        • Histologic Type - Invasive squamous cell carcinoma, keratinizing
        • Histologic Grade - G2: Moderately differentiated
        • Spread Through Air Spaces (STAS) - Present
        • Visceral Pleura Invasion - Not identified
        • Lymphovascular Invasion - Present
    • 2021-08-02 Whole body PET scan
      • The lesions of glucose hypermetabolism in the right cervical lymph nodes are old and show much less prominent compared with the previous study on 2020-09-21, indicating recurrent tumor with partial response to current therapy.
      • Glucose hypermetabolism in the mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes. Please keep follow up to exclude the possibility of distant lymph node metastasis in these regions.
      • Glucose hypermetabolism in the left lower lung, probably another primary or secondary lung cancer, suggesting biopsy for further investigation.
      • Probably inflammatory change at the left shoulder joint.
      • Recerrent hypopharyngeal cancer s/p treatment with partial response to current therapy; another primary or secondary lung cancer in the left lower lung (if proved), by this F-18-FDG PET/CT scan.
    • 2021-07-22 MRI - Larynx
      • focal increased soft tissue in the right hypopharynx. Please f/u.
      • focal enhancement in the right maxillary bone, surrounding the tooth
    • 2021-07-05 CT
      • minimal emphysema in LUL and RUL.
      • new solid nodule in LLL, primary tumor or metastasis, suggest f/u.
    • 2020-10-02 Patho - Lymph node region resection
      • pStage: rpTXN3b (cM0); rp Stage IVB (2020-10-16 ENT tumor board consensus)
    • 2020-09-21 Whole body PET scan
      • Glucose hypermetabolism in a right level IV cervical lymph node, suggesting malignant involvement in an ipsilateral regional lymph node.
      • Mild to moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change from locoregional inflammation may be considered. Please keep follow up, however, to exclude the possibility of distant lymph node metastasis in these regions.
      • Mild glucose hypermetabolism in left lower cervical lymph nodes and mediastinal lymph nodes, reactive change in response to locoregional inflammation may show such a picture.
      • Right hypopharyngeal cancer s/p CCRT with tumor recurrence, rcTxN1M0, r-stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2020-09-10 MRI - Larynx
      • an enlarged lymph node in the right lower carotid space.
    • 2020-03-10 MRI - Larynx
      • thick soft tissue, tight space, suspected residual/recurrent tumor in right pyriform sinus.
    • 2019-12-09 MRI - Nasopharynx
      • residual tumor at right pyriform sinus. no enlarged lymph node. s/p operation at left tongue and neck.
    • 2019-07-04 CT - Mediastinum
      • Recurrent tongue base tumor at right pyriform sinus, in regression as compared with previous PET/CT.
      • No evidence of tumor recurrence along the course of the esophagus.
    • 2019-06-17 Whole body PET scan
      • A glucose hypermetabolic mass in right supraglottic region, compatible with the primary lesion of laryngeal cancer.
      • Glucose hypermetabolism in the right level II and III cervical lymph nodes, suggesting malignant involvement in multiple ipsilateral regional lymph nodes.
      • Supraglottic laryngeal cancer, cTxN2bM0, stage IVA (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2019-06-14 MRI - Larynx
      • Right hypopharynx CA, T4aN2bMx stage IVA
    • 2019-06-13 Patho
      • Labeled as “right supraglottic tumor”, biopsy - Squamous cell carcinoma, moderately differentiated.
      • IHC stains: p40(+), p16(-, 0%).
    • 2017-08-02 Patho
      • Diagnosis
        • Paralysis of vocal cords or larynx, bilateral, partial; Malignant tongue neoplasm, tip and lateral; Inflammatory conditions, abscess, osteitis, osteomyelitis, periostitis, sequestrum of jaw bone; Acute gingivitis; Atrophy of salivary gland;
        • Esophagus, upper, 20cm and 30cm from incisor, biopsy - Squamous cell carcinoma.
  • Radiotherapy
    • 2020-11-06 ~ 2020-12-02
      • 3600cGy/18 fractions of the recurrent nodal with extranodal extension area.
    • 2019-09-17 ~ 2019-11-06
      • 5000cGy/25 fractions (6MV photon) of the primary hypopharyngeal to supraglottic tumor, right neck involved nodal, bilateral neck,
      • 7000cGy/35 fractions of the reduced hypopharyngeal to supraglottic tumor, right neck involved nodal area.
    • 2017-08-16 ~ 2017-09-22
      • 4500cGy/25 fractions (15MV photon) of the esophageal tumor, tract, to regional lymphatic nodal,
      • 5040cGy/28 fractions of the esophageal tumor area.
  • Chemotherapy
    • 2021-10 ~ ongoing Fluorouracil + Carboplatin + Paclitaxel
    • 2021-01 ~ 2021-06 Fluorouracil + Cisplatin + Docetaxel
    • 2020-11 ~ 2020-12 Carboplatin (CCRT)

==========

2022-03-22

  • The last medical image update occurred on 28 January 2022. Treatment with Fluorouracil + Carboplatin + Paclitaxel has been ongoing since October 2021.
  • Serum glucose(AC) remained above normal (128mg/dL 2022-03-09), however HbA1C reading went down to 7.5% (2022-03-09) from 8.0% (2021-12-06), which is a positive sign.
  • More than one year of below normal serum magnesium and above normal serum creatinine.
  • Cisplatin and, to a much lesser extent, carboplatin therapy, is associated with hypomagnesemia, more so than any other electrolyte deficiency. Hypomagnesemia affects 40%~90% of patients on cisplatin; in contrast, 10% of patients treated with carboplatin or oxaliplatin experience hypomagnesemia. Platinum-induced hypomagnesemia can persist for up to 6 years after cessation of treatment and is primarily attributed to renal Mg wasting.
  • It is possible to treat hypomagnesemia without acute symptoms with oral Mg supplementation and by eliminating medications that may be contributing to the hypomagnesemia, however, the latter may not be the optimal option during chemotherapy. MgO is presently in active medication for the patient.

701204933

220322

[objective]

  • exam finding
    • 2022-01-14 CT - whole abdomen, pelvis
      • S/P right hemicolectomy. There is no evidence of tumor recurrence.
    • 2021-12-31 Abdomen Ultrasound
      • chronic liver parenchymal disease
      • suspect GB polyp
      • cholecystopathy
      • suspect tiny stones, left kidney
    • 2021-08-26 Patho - colon segmental resection for tumor
      • Large intestine, ascending colon, laparoscopic right hemicolectomy - Adenocarcinoma, moderately differentiated
      • Lymph node, mesocolic, dissection - metastatic carcinoma
      • pT3 pN2a (if cM0) Pathology stage: IIIB.
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2 Moderately differentiated
      • Tumor Extension-Tumor invades through the muscularis propria into pericolorectal tissue with no involvement of visceral peritoneum serosal surface.
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes - Number of Lymph Nodes Involved/Examined: 4/15 with extranodal extension.
      • Ancillary Studies - The result of biopsy specimen: S2021-09938
      • IHC: EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
    • 2021-08-16 CT - whole abdomen, pelvis
      • Imaging stage: T3N1bM0, stage IIIB
    • 2021-08-03 Patho - colon biopsy
      • Intestine, large, hepatic flexure colon, biopsy - adenocarcinoma
      • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • 2021-08-03 Colonoscopy
      • suspect colon cancer, hepatic flexure, s/p biopsy
      • internal hemorrhoid
    • 2021-01-31 CT - whole abdomen, pelvis
      • suspected acute pancreatitis, suggest clinical lab data correlation.
      • small gallbladder stone. collapsed gallbladder with wall thickening, suspected chronic cholecystitis.
      • left renal stone without obstruction.
      • relative thickening renal pelvis wall, right side.
  • surgical operation
    • 2021-08-25 SILS Right-hemicolectomy - Proximal T-colon tumor
  • chemotherapy
    • 2021-10-12 ~ ongoing - FOLFOX

[assessment]

  • The survival benefit of adding oxaliplatin to adjuvant fluoropyrimidines in patients with resected stage III colon cancer has been shown in multiple randomized trials, and benefit appears to be evident across diverse practice settings and patient subgroups.
  • After undergoing right hemicolectomy on 2021-08-25, the patient has been treated with FOLFOX regimen since mid-October 2021. There is no evidence of peripheral neuropathy mentioned in nursing notes or medical records in 2022.

701355468

220322

{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}

[objective]

  • radiotherapy
    • 2022-01-17 ~ 2022-03-07 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.

==========

2022-03-22

  • On 2022-01-11, the cancer multidisciplinary meeting recommended pre-operative CCRT for this patient.
  • The patient has been undergoing CCRT treatment since mid-January 2022, and has started the FOLFOX regimen during this hospital stay.
  • There were no extreme anomalies in the laboratory data reported on 2022-03-17, 18, 21.
  • In nursing notes, adverse events of grade 0 have been recorded at 11:55 on 2022-03-22.
  • No issue with current medication.

2022-02-22

  • this 78-year-old male diagnosed with malignant neoplasm of rectosigmoid junction in early Jan 2022 is on pre-Op CCRT since mid-Jan.
  • lab data reported on 2022-02-16 showed no dysfunction of liver and kidney, and slightly lower blood counts.
  • hypertension, gout and HBV are under treatment of corresponding self-carried drugs
    • bisoprolol, valsartan
    • febuxostat
    • entecavir
  • no issue with current medication.

701312127

220321

[objective]

  • exam finding
    • 2022-03-07 Chest PA/AP view
      • Normal heart size.
      • Tortous aorta with calcification is noted.
      • S/p port-A placement with its tip at Superior vena cava.
      • Faint aveolar opacity over RIGHT LOWER LOBE is found.
      • Right pleural effusion is found.
    • 2022-02-21 CT - abdomen, pelvis
      • Mild progression of lymphoma.
      • Right pleural effusion with adjacent lung collapse. Some nodules at bil. lungs.
    • 2022-02-09 Chest PA (Erect) view
      • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
      • Enlargement of cardiac silhouette.
      • Blunting of bilateral costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-01-10 CT - abdomen, pelvis
      • Follicular lymphoma S/P C/T show partial response.
    • 2021-10-08 Chest AP
      • S/P port-A implantation.
      • Enlargement of cardiac silhouette.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2021-10-05 Ga-67 Whole body inflammation scan with SPECT
      • Increased radiotracer uptake in bilateral lungs, bilateral pulmonary hilar regions, left mediastinum, stenum, spines, and S-I joints, the nature is to be determined (lymphoma involving regions, inflammation or other nature ?).
      • Increased radiotracer accumulation in the colon, probably physiological radiotracer accumulation.
      • No prominent abnormal focal radiotracer uptake is noted elsewhere.
    • 2021-10-01 CT - whole abdomen, pelvis
      • Follicular lymphoma S/P C/T show partial response.
    • 2021-07-19 Patho - bone marrow biopsy
      • Bone marrow, biopsy - B-cell lymphoma involvement
      • Microscopically, it shows positive for B-cell lymphoma composed of foci of lymphoid aggregation with follicular architecture.
      • IHC: CD20(+), Bcl-2(+), CD10(+), MPO(+), Bcl-6(+, at germinal center), CD71(focal+), CD117(-), CD34(-).
    • 2021-07-16 Chest PA (Erect) view
      • S/P port-A implantation.
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Increased lung markings on both lower lung are noted.
    • 2021-07-16 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and sacrum (stage IV).
      • Mildly and diffusely increased FDG uptake in the bone marow of the skeleton. The nature is to be determined (lymphoma? bone marrow hyperplasia?).
    • 2021-07-12 Patho - lymphnode biopsy
      • Lymph node, right axillary, sono guide biopsy - Follicular lymphoma, grade 2
      • Histology type: B-cell neoplasms, Follicular lymphoma, grade 2
      • IHC: CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), Cyclin D1(-), CD56(-), and CK(-).
    • 2021-07-09 CT - CTA, chest
      • Diffuse enlarged lymph nodes, suspected lymphoma.
      • Bilateral pleural effusion with lung collapse.
      • GB stone.
      • Ascites.
  • Chemotherapy
    • 2022-03-18 - bendamustine + obinutuzumab
    • 2022-02-09 - rituximab
    • 2021-11-17 - R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
    • 2021-10-27 - R-CHOP
    • 2021-09-22 - R-CHOP
    • 2021-09-01 - R-CHOP
    • 2021-08-03 - R-CHOP
    • 2021-07-19 - R-CHOP
      • R-CHOP Regimen - An immunochemotherapy regimen consisting of rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride (doxorubicin hydrochloride), vincristine (Oncovin) and prednisone used to treat both indolent and aggressive forms of non-Hodgkin lymphoma.
        • Regimen - cycle length 21 days.
          • Rituximab
            • 375 mg/m2 IV
            • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count >=5000/microL.
            • Day 1
          • Cyclophosphamide
            • 750 mg/m2 IV
            • Dilute in 250 mL NS or D5W and administer over 30 minutes.
            • Day 1
          • Doxorubicin
            • 50 mg/m2 IV
            • Dilute in 50 mL NS or D5W and administer over three to five minutes.
            • Day 1
          • Vincristine
            • 1.4 mg/m2 IV (max dose 2 mg)
            • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
            • Day 1
          • Prednisone
            • 100 mg orally
            • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5.
            • Days 1 to 5
        • Pretreatment considerations:
          • Hydration
            • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
          • Emesis risk
            • MODERATE (30 to 90% risk of emesis).
          • Prophylaxis for infusion reactions
            • Premedicate with acetaminophen and diphenhydramine, with or without an H2 blocker, 30 minutes prior to at least the first and second infusions of rituximab.
          • Vesicant/irritant properties
            • Doxorubicin and vincristine are vesicants; avoid extravasation.
          • Infection prophylaxis
            • The risk of febrile neutropenia with this regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors should be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.
          • Dose adjustment for baseline liver or renal dysfunction
            • Adjustment of initial cyclophosphamide, doxorubicin, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of cyclophosphamide may be required for renal dysfunction.
          • Hepatitis screening
            • Patients should be screened for hepatitis B and C virus prior to starting rituximab, and if positive, considered for antiviral prophylaxis.
          • Cardiac screening
            • LVEF should be evaluated prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation. Infusion times and schedule may be adjusted to decrease the risk of cardiotoxicity in individuals at high risk for its development.
          • Neurotoxicity
            • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
        • Monitoring parameters:
          • CBC with differential and platelet count weekly during treatment.
          • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
          • LVEF should be evaluated periodically based on LVEF at initiation of therapy and cumulative dose of doxorubicin.
          • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.
        • Suggested dose modifications for toxicity:
          • Myelotoxicity
            • Treatment should be delayed until ANC is >1500/microL and platelet count is >100,000/microL. If a patient develops grade 4 (ANC <500/microL) neutropenia or febrile neutropenia with any cycle, G-CSF support is added to the regimen for subsequent cycles. If grade 4 neutropenia or febrile neutropenia occurs despite G-CSF support, or if the patient develops grade 3 (25,000 to 50,000/microL) or 4 (<25,000/microL) thrombocytopenia with any cycle, the doses of cyclophosphamide and doxorubicin should be decreased by 50% for subsequent cycles.
          • Neuropathy
            • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.

[assessment]

  • A patient with stage II, III, or IV FL is usually not cured by conventional treatment. Remissions can be achieved, but relapses are not uncommon. The treatment is intended to relieve symptoms, reverse cytopenias, and improve the quality of life. Despite not being curative, a modern therapy that incorporates anti-CD20 antibodies can prolong survival. The goal of modern chemoimmunotherapy regimens is usually to achieve a complete response, however, a significant minority of patients treated with these regimens will only show a partial response. Additional therapy (e.g., maintenance) may result in complete recovery in some of these patients. As well, for this group as a whole, some interventions, such as maintenance therapy and obinutuzumab, prolong progression-free survival but do not improve overall survival.
  • During the period of Mid-July 2021 through Mid-November 2021, this patient received R-CHOP, then had rituximab prescribed on 2022-02-09. CT images taken on 2021-10-01 and 2022-01-10 indicated partial response, however CT images taken on 2022-02-21 showed mild progression.
  • During this hospitalization, the patient begins receiving his new chemoimmunotherapy regimen of bendamustine plus obinutuzumab without issue.
  • Underlying diseases include HTN and DM (admission diagnosis), drugs for the latter have not been prescribed as active medication and no updated blood sugar lab readings found within these 3 months.

700980179

220318

{Peripheral T-Cell Lymphoma, PTCL, relapsed}

[objective]

  • exam finding
    • 2022-01-26 CT - neck
      • Necrotic tumor at right neck, much smaller in size and less enhancement as compared with CT scan on 20211228.
    • 2021-12-28 CT - neck
      • Probably abscess with deep neck infection at right upper neck. Differential diagnosis suspected necrotic tumor mass with infection.
    • 2021-11-25 Whole body PET scan
      • Increased FDG uptake in bilateral tonsils and a right upper neck lymph node, compatible with residual lymphoma. In comparison with the previous study on 20210107, the FDG avid lesions in bilateral tonsils and a right upper neck lymph node are less evident. Other previous lesions in the nasopharynx and other bilateral neck lymph nodes disappeared.
      • Increased FDG uptake in the stomach. Inflammation is more likely.
      • No prominent change is noted in the mild FDG avid lesions in some mediastinal lymph nodes, right pulmonary hilar lymph nodes and left adrenal gland, possibly more benign in nature.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • 2021-11-24 Patho - bone marrow biopsy
      • Bone marrow, biopsy - No evidence of T-cell lymphoma involvement
      • The sections show normocellular marrow (35%). M/E ratio = 4:1. The erythroid precursors are not remarkable. The myeloid cells show good maturation. The megakaryocytes are normal in number with few small megakatyocytes. No lymphoid aggregates can be found. There is no evidence of T-cell lymphoma involvement in CD20, CD3, CD4 and CD8 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2021-11-10 Patho - tonsil biopsy
      • Diagnosis
        • Tonsil, left, tumor excision — Peripheral T-cell lymphoma
        • Tonsil, right, tumor excision — Peripheral T-cell lymphoma
      • Histologic type: Peripheral T-cell lymphoma
      • Immunophenotyping: CD3(+), CD20(-), CD4(+), CD8(focal+), and CD30(focal+)
    • 2021-11-09 Frozen section
      • Tonsil, left, frozen section — Atypical lymphoid cell infiltration, compatible with lymphoma involvement.
    • 2021-11-03 CT - neck
      • C/W residual oropharyngeal lesions, mild regression as compared with CT scna on 20210106.
    • 2021-01-07 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple bilateral neck lymph nodes.
      • Milldy increased FDG uptake in some mediastinal lymph nodes and right pulmonary hilar lymph nodes. Inflammation is more likely.
      • Milldy increased FDG uptake in the left adrenal gland. The nature is to be determined (benign tumor? other nature?).
      • Increased FDG accumulation in both kidneys and right ureter. Physiological FDG accumulation may show this picture.
    • 2021-01-06 CT - neck
      • Bilateral tonsillar lesions and bilateral neck LAPs. R/O lymphoma (stage II).
    • 2020-12-28 Patho - tonsil biopsy
      • Tonsil, right, biopsy —- Malignant T-cell lymphoma
      • Histology type: T-cell neoplasms, in favor of Peripheral T-cell lymphoma
      • Immunohistochemical stain profiles: CD3(+), CD4(+), CD8(-), CD56(-), Granzyme B(-), CD30(+), ALK(-), and CK(-).
      • Fungal hyphe is seen in necrotic debris. The PAS special stain is positive.
    • 2020-12-26 Nasopharyngoscopy
      • Ulcerative lesion over right tonsil upper pole and right palatopharyngeal arch
  • chemotherapy
    • 2021-12-10 ~ ongoing Folotyn (pralatrexate)
    • 2021-01-11 ~ 2021-05-13 CHOP (cyclophosphamide, doxorubicin hydrochloride (hydroxydaunorubicin), vincristine sulfate (Oncovin), and prednisone)

[assessment]

  • Pralatrexate is indicated to treat relapsed PTCL. The patient is taking pralatrexate currently since early December 2021, and CT scans (2022-01-26 versus 2021-12-28) demonstrated improvements.
  • Hepatotoxicity and LFT abnormalities have been observed with pralatrexate use. Persistent abnormalities may indicate hepatotoxicity. In the period 2021-12-01 to now, S-GPT/ALT readings have ranged from 15U/L to 403U/L, with 77U/L being reported on 2022-03-17.
  • Package insert revealed 30% of patients treated with pralatrexate experienced edema, which should be addressed.

701148578

220318

{Nasopharyngenl Carcinoma - NPC, non-keratinizing carcinoma}

[objective]

  • Exam findings
    • 2021-11-24 PET
      • Glucose hypermetabolic lesions in the post. aspect of nasal septum, nasal cavity, and part of left NP region, compatible with recurrent tumor of NPC.
      • Glucose hypermetabolic lesions in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes.
      • Glucose hypermetabolic lesion in the right femoral shaft, the nature is to be determined (post-traumatic change, benign or even another primary malignant neoplasm of bone, or other nautre?), suggesting further investigation.
      • NPC s/p treatment with tumor recurrence, rcTxN0M0, by this F-18 FDG PET scan.
    • 2021-11-01 Patho - Larynx biopsy
      • Nasopahrynx, biopsy - Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
      • IHC: CK(+), EBER(+).
    • 2021-11-01 MRI - Nasopharynx
      • A soft tissue tumor, about 27 mm x 22 mm x 24 mm, with relatively homogeneous mild T1- and T2-hyperintensity and faint enhancement involving posterior aspect of nasal septum, posterior nostril, florr of sphenoid sinus and part of left nasopharyngeal wall.
      • Diffuse fluid accumulation in bilateral sphenoid sinuses.
    • 2020-11-02 MRI - Nasopharynx
      • Markedly regressed bil. neck LNs.
    • 2020-04-22 MRI - Nasopharynx
      • C/W NPC T4N2Mx, Stage IVA. Progressive change as compared with MRI on 2019-12-04.
    • 2019-12-05 PET
      • The FDG PET findings are compatible with nasopharyngeal malignancy with invasion to the skull base and possible intracranial extension.
      • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes and multiple right neck level II to III and left neck level II lymph nodes, compatible with metastatic lymph nodes.
      • Mild glucose hypermetabolism in the lesser trochanter of right femur. The nature is to be determined (post-traumatic change? other nature?).
    • 2019-12-04 MRI - Nasopharynx
      • Bilateral NPC, at least T4N2Mx, stage IVA.
  • Radiotherapy
    • 2020-05 ~ 2020-06:
      • 6090cGy/29 fractions (6 MV photon) to NPX tumor and bilateral neck LAPs (incomplete).
      • 2020-06-22 RT side effect evaluation: radiation mucositis, grade 2; pharyngitis, grade 2; dermatitis, grade 2; N/V, grade 1; esophagitis, grade 1; xerostomia, grade 2.
  • Chemotherapy
    • 2020-11 ~ ongoing: carboplatin + fluorouracil
    • 2019-12 ~ 2020-06: cisplatin, 2020-04-21 + UFT

[objective] ??

  • radiotherapy
    • 2022-02 ~ ?? CCRT?
  • chemotherapy
    • 2022-02-14 ~ ongoing - 5-FU + carboplatin
    • 2021-11-29 ~ 2022-01-10 - carboplatin (weekly)

2022-03-18

701240249

220315

[objective]

  • exam finding
    • 2022-03-02 Patho - bone marrow biopsy
      • pathologic diagnosis
        • Bone marrow, biopsy - acute myeloid leukemia
      • microscopic examination
        • Microscopically, the sections show a picture of acute myeloid leukemia, composed of hypercellular marrow (>90%). The marrow space is almost completely replaced by blasts.
      • Immunohistochemistry: CD34(+, 60%), CD117(+, 60%), MPO(+, 10%), CD61(+, megakaryocytes) and CD71(+, erythroid series).
    • 2022-02-25 CT - lung/mediastinum/pleura
      • Right middle lobe and right lower lobe subsegmental consolidation.
    • 2022-01-12 Patho - bone marrow biopsy
      • pancytopenia
      • Bone marrow, iliac, biopsy - Normal cellular marrow.
      • IHC stains: CD117: <2%; CD34: <2 %; MPO: 10%, CD61: <2 %; CD71: 20%, CD138: 5% (of the nucleated cells). Kappa and lambda light chains: no predominant monoclonal sub-population.
      • Section shows piece(s) of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no metastatic malignancy present.

701272755

220315

[subjective]

  • 2021-03-04 cough for several months, CT scan at ShuangHo Hospital showed a necrotic mass at anterosuperior mediastinum, suspected malignant thymoma.

[objective]

  • exam finding
    • 2022-03-11 CT - brain
      • multiple brain metastases.
    • 2022-02-17 CT - lung/mediastinum/pleura
      • s/p thymectomy with recurrent soft tissue at anterior mediastinum and lymph nodes at subcarina region. stationary as compred with previous CT.
    • 2021-1-17 Patho - soft tissue nontumor/mass/lipoma/debridement
      • subcutanoeus nodule over right back
      • diagnosis - soft tissue, back, excisional biopsy - Metastatic thymoma - Margin free
      • IHC: P40(+), CK5/6(+), CD5(focal+).
    • 2021-11-04 CT - lung/mediastinum/pleura
      • Residual low density lesion at anterior mediatinum, in regression.
      • Some lymph nodes are found at paracaval region. Stable.
      • The pleural effusion is not visualized in the current study.
    • 2021-09-08 Patho - soft tissue nontumor/mass/lipoma/debridement
      • Diagnosis - Skin and soft tissue, previous right chest tube wound, excisional biopsy - metastatic thymoma
      • IHC: CK5/6(+), p40(+), CD5(-), and CD117(-). The results are consistent with metastatic thymoma. The deep resection margin is involved by tumor.
    • 2021-08-03 CT - lung/mediastinum/pleura
      • recurrent or residual mediastinal invasive thymoma with mediastinal LAP and bilateral pleural effusions suspected mediastinal abscess.
    • 2021-04-13 Patho - meiastinum mass
      • anterior mediastinal tumor with pericardial and LUL invasion
      • Thymus, excision - Invasive thymoma, poorly differentiated, AJCC 8th edition: pStage IIIA, pT3N0 (if cM0), at least
        • The peripheral resection margin is involved
      • Lung, LUL, wedge resection - Invasive thymoma, by direct invasion, with negative resection margin.
      • IHC CK5/6(+), p63(+), CD117(-), CD5(-), TTF-1(-), GATA3(-) and CD56(-).
    • 2021-03-18 Patho - thymus tumor
      • Mediastinal tumor
      • Diagnosis: Thymus, CT-guide needle biopsy - in favor of invasive thymoma
      • IHC: CK5/6(+), p63(+), TTF-1(-), Naspin A(-), CD56(-), Calretinin(-), PAX8(-), and CD117(-). The results are in favor of invasive thymoma, but metastatic squamous cell carcinoma or urothelial carcinoma can not be excluded.
  • surgical operation
    • 2021-09-08
      • Surgery: Removal of granuloma
      • Finding: Erythematous granuloma over previous right chest tube wound. suspected stitches-related and tumor seeding.
    • 2021-04-12
      • Surgery: Radical left side pericardiectomy with tumor mobilization and excision.
      • Finding: A huge, stiff anterior mediastinal mass tightly adhered to ASAo/MPA and extended to left anterior chest wall. We meticulously divided the InV and LIJV and tumor debulking from surroundings.
  • radiotherapy
    • 2021-05-14 ~ 2021-07-05: 4500cGy/25 fractions of the thymic tumor, and 6480cGy/36 frcations of the reduced thymic tumor area.
  • chemotherapy
    • 2022-01-06 vincristine + cyclophosphamide
    • 2022-01-05 cisplatin + doxorubicin
    • 2021-12-01 vincristine + cyclophosphamide
    • 2021-11-29 cisplatin + doxorubicin
    • 2021-10-20 vincristine + cyclophosphamide
    • 2021-10-18 cisplatin + doxorubicin
    • 2021-09-20 vincristine + cyclophosphamide
    • 2021-09-20 cisplatin + doxorubicin
    • 2021-08-11 vincristine + cyclophosphamide
    • 2021-08-09 cisplatin + doxorubicin
    • 2021-07-13 vincristine + cyclophosphamide
    • 2021-07-13 cisplatin + doxorubicin
    • 2021-05-15 ~ 2021-06-29: cisplatin (part of CCRT)

700309329

220309

{rt breast ca (TNBC), cT2N0M0 stage IB}

  • exam finding
    • 2020-11 recurrence
  • surgical operation
    • 2018-10 at WanFang Hospital
  • chemotherapy
    • ongoing oral vinorelbine
    • 2021-05 ~ 2021-10 Eribulin / Xeloda
    • 2021-02 ~ 2021-04: Taxol + Gem
    • 2020-12 ~ 2021-01 EP x 3
    • 2018-18 ~ ?: post-Op adjuvant CAP
    • 2018-07 ~ 2018-09 pre-Op neoadjuvant TAC x 3
    • 2018-05 ~ 2018-06 pre-Op neoadjuvant C/T x CEF x 3
  • shared decision making
    • 2022-03-01
      • effective Tx option had been tried and failed. hospice care had been recommended at WanFang Hospital.

[assessment]

  • Use of preoperative systemic therapy may provide important prognostic information based on response to therapy. Achieving a pathologic complete response (pCR) to neoadjuvant therapy is associated with favorable disease-free and OS in early-stage breast cancer. The correlation between pathologic response and long-term outcomes in patients with early-stage breast cancer is strongest for patients with triple-negative breast cancer.
    • references:
      • Liedtke C, Mazouni C, Hess KR, et al. Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin Oncol 2008;26:1275-1281. https://www.ncbi.nlm.nih.gov/pubmed/18250347.
      • Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet 2014;384:164-172. http://www.ncbi.nlm.nih.gov/pubmed/24529560.
      • von Minckwitz G, Untch M, Blohmer JU, et al. Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol 2012;30:1796-1804. https://www.ncbi.nlm.nih.gov/pubmed/22508812.
  • Different subsequent chemotherapy regimen did not yield satisfactory results for this patient.
  • Biomarkers such as BRCA1/2, PIK3CA, PD-L1, NTRK, MSI-H/dMMR, or TMB-H not found in the system, or targeted drugs may provide an alternative approach.

700835850

220304

[subjective]

  • 2021-12 the patient noted vaginal bleeding and coital pain after sexual intercourse, and post-voiding vaginal bleeding developed afterwards.

[objective]

  • exam finding
    • 2022-01-25 Patho - uterus neoplastic
      • pathologic diagnosis
        • Tumor, uterine endocervix, radical hysterectomy - Carcinosarcoma
        • Tumor, uterine fundus, ditto - Serous carcinoma, high grade
        • Myometrium, ditto - Tumor invasion, less than half thickness
        • Parametria, bilateral, ditto - Free from tumor, two reactive lymph nodes at R’t parametrium
      • AJCC pathological stage
        • endometrial cancer - pT1aN0, if cM0, stage IA
        • cervical cancer - pT1b1N0, if cM0, stage IB1 / FIGO stage IA1
      • Microscopic examination
        • Tumor 1
          • Tumor location: Fundus
          • Myometrium involvement: involved, less than 0.2 cm in depth
          • Tumor type: high grade serous carcinoma
          • Histologic grade: high grade
          • Immunohistochemistry: P16(+), P53(+), WT-1(+, focal), ER(+, focal) and PR(+, focal)
        • Tumor 2
          • Tumor location: Between low body and endocervix
          • Corpus involvement: involved, focal
          • Tumor type: homologous type carcinosarcoma
          • Histologic grade: high grade
          • Depth of invasion: less than 0.1 cm, <1/2 cervical wall
          • Immunohistochemistry:
            • carcinoma component: P16(+), P53(+), WT-1(+, focal), CK(+), vimentin(-), CD10(-)
            • Sarcoma component: vimentin(+), CD10(+, focal), WT-1(+, focal), P16(+), P53(+), CK(-)
    • 2022-01-11 MRI - pelvis
      • Clinical cervical polypectomy, carcinosarcoma. No evidence of advanced lesion.
      • Soft tissue in the uterine cavity (fundus and lower body), suspected polyps or endometrial tumors, suggest further study.
    • 2022-01-03 Patho - cervix/endometrial polyp
      • pathologic diagnosis
        • Uterus, cervix, polypectomy - Carcinosarcoma
      • microscopic examination
        • The sections show carcinosarcoma, composed of a adenocarcinomatous component admixed with a high-grade sarcomatous component.
  • surgical operation
    • 2022-01-24 radical hysterectomy
  • radiotherapy
    • 2022-02-18 ~ 4500cGy/25 fractions of the pelvis, and 1200cGy/3 fractions by IVRT to vaginal cuff mucosa surface.
  • chemotherapy
    • 2022-03-03 ~ ongoing: cisplatin

[assessment]

  • Surgical findings without nodes, margins and parametrium infiltrations, s/p radical hysterectomy (2022-01-24), pelvic EBRT and concurrent platinum-containing chemotherapy were recommended for stage IB1 cervical cancer.
  • concurrent platinum-containing chemotherapy with EBRT utilizes cisplatin as a single agent. currently, the patient is being hospitalized to receive her first chemotherapy dose. in case of cisplatin intolerance, carboplatin may be used instead.
  • regular cytology can be considered for detection of lower genital tract dysplasia and for immunocompromised patients, although its value in detection of recurrent cervical cancer is limited.

700267431

220303

{Compatibility for both Tapimycin and KCl in Suntose}

  • tapimycin in suntose: compatible
  • potassium chloride in suntose: compatible
  • both tapimycin and KCl in suntose: no compatibility data availabe yet, not recommended.

700334023

220303

{Panceratic carcinoma, cT1N1M1 (left neck subclavicle mets), stage IV}

[objective]

  • exam finding
    • 2022-01-17 CT - lung/mediastinum/pleura
      • distal pancreatic cancer with regression of neck LNs metastases but progression of retroperitoneal para-aortic LNs metastases, new left adrenal metastasis, and resolution cystic component at pancreatic tail as compared with previous chest, neck, and abdominal CT exams.
      • favor hepatic cysts, cannot totally rule out small metastatic lesions, stationary
    • 2021-10-11 CT - neck
      • multiple left low neck and supraclavicular fossa LAPs.
    • 2021-09-20 CT - liver, spleen, biliary duct, pancreas
      • A soft tissue nodule (2.5cm) at LUQ.
      • Enlarged LNs at paraaortic region.
    • 2021-06-12 CT - whole abdomen, pelvis
      • metastatic paraaortic lymph nodes with partial response.
      • atrophy of pancreatic tail with dilated P-duct.
      • suspected liver cysts.
    • 2021-03-05 Patho - lymphnode biopsy
      • tissue, intraabdominal lymph node, biopsy - poorly differentiated carcinoma
      • IHC: CK7(+), CDX-2(+), CK(+), CK20(-).
    • 2021-03-05 Cytology
      • positive for malignancy
      • smears show clusters of atypical tumor cells with nuclear hyperchromasia, pleomorphism and high N/C ratio.
    • 2021-03-04 Whole body PET scan
      • Glucose hypermetabolism in the hypopharynx. The nature is to be determined (inflammation/infection? malignancy?).
      • A glucose hypermetabolic in the left upper abdomen just between the stomach and spleen. Malignancy (colon malignancy?) in this region should be watched out. However, no prominent abnormal focal FDG uptake was noted in the pancreas.
      • Glucose hypermetabolism in multiple left neck level V and left supraclavicular lymph nodes, a mediastinal A-P window lymph node and multiple abdominal paraaortic and right plevic lymph nodes, compatible with multiple metastatic lymph nodes.
      • Mild glucose hypermetabolism in the stomach, some mediastinal right paratracheal lymph nodes, right pulmonary hilar lymph nodes and a left axillary lymph node. Inflammatory process is more likely.
    • 2021-02-22 Patho - soft tissue
      • Lymph node, left neck, excision - metastatic carcinoma, poorly differentiated consistent with gastrointestinal or pancreatobiliary origin
      • IHC: CK7(focal +), CK20(-), CDX2(+), CK5/6(-), TTF-1(-), CD56(-), and GATA3(-).
    • 2021-02-18 CT - lung/mediastinum/pleura
      • Atrophy of the pancreatic tail with dilated distal pancreatic duct is found. suspected IPMT, suggest EUS/ERCP.
      • Lymphadenopathy at left thoracic inlet and paraaortic region.
  • surgical operation
    • 2021-02-22 Excision - a 1.5x2x2 cm soft tumor over L’t supraclavicle region.
  • chemotherapy
    • 2022-02 ~ ongoing: 5-Fu + leucovorin + irinotecan liposome, Q2W
    • 2021-04 ~ 2022-01: gemcitabine + nal-paclitaxel, Q2W
    • 2021-03: gemcitabine

[assessment]

  • Most recent CT images (2022-01-17) showed regression of neck LNs metastases, progression of retroperitoneal para-aortic LNs metastases, new left adrenal metastasis. Each metastasis has its own ups and downs. In general, the disease is still advancing.
  • FOLFIRINOX or modified FOLFIRINOX should be limited to those with ECOG 0-1.
  • Gemcitabine + albumin-bound paclitaxel is reasonable for patients with ECOG 0-2. (Apr 2021 to Jan 2022)
  • 5-FU + leucovorin + liposomal irinotecan is a reasonable subsequent therapy option for patients with ECOG 0-2. (since Feb 2022)
  • Sympathomimetics for glaucoma prescribed by ophthalmology OPD might be added as a self-carried item into current medication.

701252496

220302

[objective]

  • exam finding
    • 2022-03-01 CT
      • bilateral lung, mediastinal and supraclavicular LNs, chest wall, pleural, bony, and liver metastases, in progression as compared with CT on 2022-01-19.
      • multiple numerous nodules of variable sizes throughout in both lungs due to metastasis.
    • 2022-01-19 CT
      • bilateral lung, mediastinal and supraclavicular LNs, chest wall, pleural, and liver metastases, in progression as compared with CT on 2021-11-09.
      • multiple numerous nodules of variable sizes throughout in both lungs due to metastasis.
    • 2021-12-20 Pelvis & Bilat. Hip Lat
      • osteolytic bony lesion in left lower sacrum and right pubic bone are suspected.
    • 2021-12-01 Hearing test
      • bil. moderately severe to profound HL.
    • 2021-11-09 CT
      • bilateral lung, mediastinal LNs, chest wall, and liver metastases, in progression as compared with CT on 2021-09-06.
    • 2021-09-06 CT
      • bilateral lung, mediastinal LNs, chest wall, and liver metastases, in progression as compared with CT on 2021-07-02.
    • 2021-07-02 CT
      • esophageal cancer s/p esophagectomy and gastric tube reconstruction. No regional recurrence is found.
      • bilateral lung meta with enlarged size is found.
      • s/p jejunal stomy.
    • 2021-03-24 Patho - soft tissue biopsy / simple excision (non lipoma)
      • skin, infra-gluteal fold, right, excision - metastatic adenosquamous carcinoma, compatible with esophageal primary
    • 2021-03-16 CT
      • favor bilateral lung and mediastinal LNs metastases and bronchiolitis or endobronchial spreadinf nodules, and residal posterior wall thickening at M/3 of esophages
    • 2021-02-01 Patho - soft tissue biopsy / simple excision (non lipoma)
      • skin, scalp, incisional biopsy - compatible with metastatic adenosquamous carcinoma from esophagus
      • IHC: CK7(+), CK5/6(+), and p63(focal +).
    • 2021-01-19 Patho - esophagus subtotal/total resection
      • Esophagus, middle third, VATS esophagectomy - Adenosquamous carcinoima, poorly differentiated, s/p CCRT
      • Soft tissue, peri-gastric, specimen 1, dissection - Adenosquamous carcinoima, metastatic (1/10)
      • Lymph node, group 5, dissection - Adenosquamous carcinoima, metastatic (1/2)
      • Pathology stage:
        • ypStage IIIB, ypT3N1(if cM0)
        • if brain metastasis is proofed, ypStage IVB, ypT3N1(if cM1)
    • 2021-01-06 Whole body PET scan
      • The glucose hypermetabolic lesions in the middle portion of the esophagus, in mediastinal lymph nodes, and in bilateral pulmonary hilar lymph nodes come to less evident compared with the previous study on 2020-10-16, compatible with esophageal malignancy s/p treatment.
      • However, glucose hypermetabolic lesions in the left lower lung and right lower lung become more prominent, suggesting lung metastases.
    • 2021-01-05 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2020-10-13, the lesion in the region about left 3rd costovertebral junction is new. The nature is to be determined (post-traumatic change? other nature?).
      • No prominent change is noted in other bone lesions, possibly more benign in nature.
    • 2021-01-05 MRI - Brain
      • A small enhancing nodule in right caudate nucleus head. Seems slightly increase in size (4.7 mm), suggest follow up.
      • Brain atrophy.
    • 2021-01-04 CT
      • M/3 thoracic esophageal cancer, significant regression of a sessile like intralumal mass in posterior wall as compared with CT on 2020-09-30.
      • no regional LAP. inflammation or infection in RLL and LLL of lungs.
    • 2020-10-23 MRI - Spectroscopy
      • An enhancing lesion (3 mm) in right caudate nucleus. Metastasis is first considered until proved otherwise.
    • 2020-10-16 Whole body PET scan
      • A glucose hypermetabolic lesion involving the middle portion of the esophagus, compatible with primary esophageal malignancy. Besides, there were two small focal areas of glucose hypermetabolism in the lower portion of the esophagus. Esophageal malignancy involving these two small focal areas should be considered.
      • Glucose hypermetabolism in multiple bilateral supraclavicular lymph nodes and multiple mediastinal lymph nodes (more than 7 lymph nodes), in bilateral pulmonary hilar lymph nodes and in two upper abdominal lymph nodes. Metastatic lymph nodes may show this picture.
      • Some small glucose hypermetabolic lesions in bilateral lung fields. Lung metastases should be watched out.
    • 2020-10-15 Patho - Esophageal biopsy
      • Esophagus, 34, 37-38 cm below incisors, biopsy - Squamous cell carcinoma, poorly differentiated
    • 2020-10-15 MRI - Brain
      • A metastatic lesion (3 mm) in right caudate nucleus. Left lateral nasopharyngeal mucosal thickening.
    • 2020-09-30 CT
      • Esophageal Carcinoma
      • Imaging stage: T2N1M0, stage IIIA
    • 2020-09-28 Patho - Esophageal biopsy
      • Esophagus, middle third, 25-30 cm below incisor, biopsy - Squamous cell carcinoma, poorly differentiated
    • 2020-09-28 Esophagogastroduodenoscopy, EGD
      • Suspect esophageal cancer, middle third, 25-30 cm below incisor s/p biopsy x 3
  • surgical operation
    • 2021-01-18 VATS + esophagectomy + laparoscopy gastric tube reconstruction
  • radiotherapy
    • 2021-02-22 ~ 2021-03-05 18Gy/6fx to the whole brain The .
      • whole brain: 18Gy/6fx
      • rt caudate nucleus metastatic tumor: 30Gy/10fx
      • scalp boost: 9Gy/3fx (4MeV electron)
    • 2020-11-02 ~ 2020-12-11 50.4Gy/28fx to the esophagus, Rt hilar LAPs, and adjacent lymphatic drainage area (part of preOp neoadjuvant CCRT)
  • chemotherapy
    • 2021-12 ~ ongoing: 5-Fu + cisplatin + paclitaxel
    • 2021-07 ~ 2021-11: FOLFIRI
    • 2021-03 ~ 2021-07: 5-Fu + cisplatin + docetaxel
    • 2020-11 ~ 2020-12: 5-Fu + cisplatin (PF, part of preOp neoadjuvant CCRT)

==========

2022-03-02

  • for recurrent, metastatic esophageal squamous cell carcinoma with general weakness and fatigue, if ECOG score <= 2 or Karnofsky score >= 60%, then microsatellite and PD-L1 testing might be performed for those previously not done, to expand the subsequent choice like nivolumab or pembrolizumab.
  • if NTRK gene fusion positive proved, entrectinib or larotrectinib could also serve as an optional choice.

2021-05-17

[tube feeding]

The oral drugs in active medication including:

  • keto (ketorolac 10mg)
  • neurontin (gabapentin 100mg)
  • tramacet (tramadol 37.5mg, acetaminophen 325mg)

All the above drugs can be grinded and administrated via NG tube

700867682

220301

[objective]

  • diagnosis
    • 2022-01-26 dischargenote
      • Recurrent hepatocellular carcinoma, rypT3N0(cM0), Stage IIIA; status post 3rd Transarterial chemoembolization on 2022-01-25, BCLC: B, ECOG:1
      • Liver cirrhosis with moderate splenomegaly, child score: A
      • Hypertension
      • Type 2 diabetes mellitus without complications
      • Enlarged prostate without lower urinary tract symptoms
  • exam finding
    • 2022-02-25 MRI - L-spine
      • multiple bone tumors
      • herniated discs in the L2/3, L3/4 and L4/5 discs
      • mild spondylolisthesis at L4-5
    • 2022-01-17 MRI - Liver, Spleen
      • HCC s/p operation. Liver cirrhosis with splenomegaly. Multiple recurrent HCCs (up to 2.0cm) in liver.
    • 2021-11-19 CT - ABD
      • Four newly-developed HCCs or pseudolesions in S8 and S2 are suspected? Please correlate with MRI.
      • Viable HCC in S7 of the liver is suspected. Please correlate with MRI.
    • 2021-09-09 MRI
      • HCC at right lobe liver up to 6.6cm with several satellite smaller lesions at right lobe.
      • Lymphadenopathy at retroperitonum, paraaoritc and hepatic hilar region.
    • 2021-08-25 CT - ABD
      • HCC 6.8 x 4.6 cm in S7 of the liver is suspected. Please correlate with AFP and MRI to evaluate the tumor margin.
      • Two Recurrent HCCs 1.4 cm in S7 and 1.1 cm in S6 of the liver are suspected. The differential diagnosis include dysplastic nodules. Please correlate with MRI.
      • HCC or flow artifact 1.6 cm in S5 liver is suspected.
    • 2021-08-16 SONO - ABD
      • HCC status post S5 segmenectomy and cholecystectomy
      • Fatty liver, moderate
      • Liver cirrhosis with moderate splenomegaly
      • Fatty pancreas
      • Left renal stone
    • 2021-07-28 SONO - Kidney
      • Bilateral chronic change with large sized kidney suspect diabetic nephropahty
      • Left renal stone
    • 2020-04-17 SONO = Kidney
      • Left moderate hydronephrosis
    • 2019-03-11 Surgical pathology Level V
      • Pathologic diagnosis
        • Liver, S5, partial hepatectomy - Hepatocellular carcinoma
        • Pathologic Staging: pT1bNx(cMx); Stage IB at least
      • Microscopic examination
        • Histologic type: Hepatocellular carcinoma, predominantly clear cell
        • Histologic Grade: G3 (Poorly differentiated)
        • Cytological grade: Grade III
        • Tumor necrosis: Present (10%)
        • Inflammatory cell infiltration: Moderate
        • Tumor capsule: Partially ncapsulated with infiltrative border
        • Satellite nodule: Absent
        • Bile duct Invasion: Absent
        • Hepatitis: Non-B, non-C
        • Ishak Modified HAI Grading: Score=3 (interphase hepatitis=0/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
        • Fatty Change: Marked (70%)
    • 2019-02-26 Visceral Angiography 2 vessels
      • Right hepatic tumor suspected HCC
    • 2019-02-26 Echo for liver, gall bladder, pancreas, spleen
      • Fatty liver , severe
      • Liver tumor, S5, suspicious HCC
      • Renal stone, left
      • Accessory spleen
    • 2019-01-30 SONO - ABD
      • Bilateral parenchymal renal disease.
      • Left mild hydronephrosis.
      • Left renal stones.
      • Liver tumor.
  • Lab data
    • AFP
      • 2022-01-17 103 ng/mL
      • 2021-10-26 19
      • 2021-08-16 20
      • 2019-02-26 2
    • S-GPT/ALT
      • 2022-01-26 92 U/L
      • 2022-01-17 35
      • 2021-12-07 28
      • 2021-12-01 62
      • 2021-10-26 22
      • 2021-09-24 43
    • S-GOT/AST
      • 2022-02-27 97 U/L
      • 2022-01-26 279
      • 2022-01-17 112
      • 2021-12-01 87
      • 2021-10-26 26
      • 2021-09-24 53
      • 2021-09-22 36
  • Embolization
    • 2022-01-25 Embolization (TAE) - ABD for tumor
      • HCCs at both hepatic lobes s/p TACE.
    • 2021-11-30 Embolization (TAE) - ABD for tumor
      • HCCs at RIGHT hepatic lobe s/p TACE.
    • 2021-09-23 Embolization (TAE) - ABD for tumor
      • HCCs at RIGHT hepatic lobe s/p TACE.
  • Radiotherapy
    • 2021-10-05 ~ 2021-11-08: 5000cGy/25 fractions (15 MV photon) to hepatic hilum & paraaortic LAPs.
  • Medication
    • 2021-01 ~ ongoing: lenvatinib 10mg QD
    • 2021-10-12, -10-26, -11-30: nivolumab 100, 100, 40mg, respectively
    • 2021-09 ~ 2022-01: sorafenib 200mg BIDAC

[assessment]

  • Recurrent HCC progressed, bone mets observed by MRI on 2022-02-25 s/p 3 times of TAE in 2021-09, 2021-11, 2022-01, s/p nivolumab (Oct, Nov 2021), sorafenib (Sep 2021 ~ Jan 2022) and lenvatinib (since Jan 2022).
  • Neither pembrolizumab nor atezolizumab used in advanced HCC setting are covered by the most updated NHI policy (2022-02-23 version). However atezolizumab/bevacizumab for Child-Pugh Class A patients is recommended as a preferred regimen by NCCN (2021 version 5).
  • First-line nivolumab treatment did not significantly improve overall survival compared with sorafenib, but clinical activity and a favourable safety profile were observed in patients with advanced hepatocellular carcinoma. Thus, nivolumab might be considered a therapeutic option for patients in whom tyrosine kinase inhibitors and antiangiogenic drugs are contraindicated or have substantial risks.
  • There are limited data supporting the use of FOLFOX, and use of chemotherapy in the context of a clinical trial is preferred.
  • If NTRK gene fusion is positive, then larotrectinib or entrectinib might be opt-in as subsequent line use.
  • Lenvatinib was non-inferior to sorafenib in overall survival in advanced hepatocellular carcinoma. This drug is prescirbed as part of current medication.
  • In addition to dermatologic adverse effects, since lenvatinib could increase the possibility of hypertension (45% to 73%; severe hypertension 3%; UpToDate) which is a underlying disease the patient has, a closer blood pressure monitoring might be needed.

700962200

220301

{myelodysplastic syndrome}

[objective]

  • exam finding
    • 2022-02-16 Patho - bone marrow biopsy
      • Diagnosis - Bone marrow, biopsy - Compatible with myelodysplastic syndrome
      • IHC:
        • MPO: positive for myeloid series
        • CD71: positive for erythroid series
        • CD61: positive for megakaryocytes
        • CD117: positive for blast
        • CD34: positive for blast
      • Microscopically, the sections show pictures as follows:
        • Cellularity 30-40%
        • M/E ratio about 1/2, left shift maturation of both myeloid and erythroid series
        • Megakaryocyte proliferation, 30% with dysplastic change. Immunohistochemistry of CD34(+) and CD61(+)
        • Blast cells about 5%
        • According to all above histopathologic findings and clinical presentation, it is compatible with myelodysplastic syndrome.
    • 2021-09-27 Patho - bone marrow biopsy
      • Bone marrow, buttock, biopsy - Hypocellularity
      • IHC:
        • MPO: positive for myeloid series
        • CD71: positive for erythroid series
        • CD61: positive for megakaryocytes
        • CD117: positive for blast
        • CD34: positive for blast
      • Microscopic examination
        • Hypocellularity for her age, 5-10%
        • M/E ratio about 1/3, hypoplasia of myeloid series and hyperplasia of erythroid series
        • Megakaryocyte proliferation, 20-30% with interstitial or paratrabecular distribution
        • No obviously increase of blast (5%)
        • According to all above histopathologic findings and clinical history, the differential diagnosis includes myelodysplastic syndrome (MDS) or therapy-associated reactive change.
    • 2020-09-04, -08-14 CT
      • S/P hysterectomy.
      • Hepatosplenomegaly, nature?
    • 2019-10-17 Tc-99m MDP whole body bone scan
      • Increased activity in the middle T-spines and L4-5 spines. Degenerative change may show this picture.
      • Increased activity in the maxilla. The nature is to be determined (dental problem? other nature?).
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?).
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, elbows, knees and right ankle. Benign joint lesion is more likely.
    • 2016-05-17 Pathology
      • Uterus, endometrium, staging surgery - carcinosarcoma, Grade 3
      • pTNM: pT1bNO(cM0) , FIGO stage: IB.
      • Uterus, myometrium, staging surgery - involved by carcinosarcoma (> 1/2 thickness) - adenomyosis.
    • 2016-05-06 MRI
      • Endometrial tumor, suspected malignancy, cstage T1aN0Mx.
  • surgical operation
    • 2016-05-10 laparoscopic gynecology staging surgery (LAVH + BSO + BPLND + omentectomy); laparoscopic adhesionolysis.
  • radiotherapy
    • 2016-06-16 ~ 2016-08-01: 4500cGy/25fx (15MV photon) of the pelvic, and 900cGy/3fx via IVRT to vaginal cuff mucosa surface area.
  • chemotherapy
    • 2016-06-01, -06-23, -08-10, -09-06, -11-14.

[assessment]

  • Allogeneic hematopoietic cell transplantation (HCT) is the treatment with the highest potential to cure MDS. However, because of advanced age, comorbid conditions, lack of adequately matched donors, and/or patient preferences, only a small subset of patients with MDS are candidates for allogeneic HCT. HLA typing should be performed if hematopoietic cell transplant (HCT) approach is not ruled out.
  • For most patients with MDS, the goals of care are to lessen symptoms, improve the quality of life, and prolong survival, while minimizing treatment-related toxicity. IPSS/IPSS-R could be applied to categorize prognostic risk group.
  • If del(5q) is confirmed, then lenalidomide might be considered for IPSS low/intermediate MDS.
  • lab data uric acid 11.8, eGFR 30.11 reported on 2022-02-28, allopurinol (50 mg daily) or febuxostat (no dosage adjustment necessary) might be considered if no contraindication.

701049704

220301

[objective]

  • underlying disease
    • ESRD and dependence on renal dialysis (QW135)
  • exam finding
    • 2021-12-23 CT
      • Right hilar lung meta, in regression.
      • Mediasitnal lymphadenopathy, regressed.
      • s/p left nephrectomy.
    • 2021-09-24 CT
      • Bladder ca. with right pulmonary hilar meta, causing right lung partial collapse and bilatral pleural effusion. The tumor is stationary in size and extension.
    • 2021-08-13 CT
      • Lung metastases show decreasing in size.
    • 2021-04-21 bronchoscopy
      • right main residual endobronchial tumors s/p electrocautery.
      • RUL and right intermediate bronchus endobronchial tumors, cannot be approached.
    • 2021-04-21 patho - bronchus biopsy
      • sections show solid sheets of hyperchromatic tumor cells in a fibrotic stroma. keratinization is focally seen.
      • IHC: CK5/6(+), p63(+), GATA3(+), TTF-1(-), and CD56(-). the results are consistent with metastatic urothelial carcinoma.
    • 2021-04-16 bronchoscopy
      • autofluorescence: abnormal mucosa over right main bronchus
      • right main bronchus: total occlusion by tomor s/p biopsy for 1 specimen with mild bloody oozing s/p epinephrin 0.5 amp local spray
      • EBUS: endobronchial tumor over right main bronchus.
    • 2021-03-25 chest PA (erect) view
      • extensive opacification and volume reduce and nodular opacities over Rt lung, in progression associated Rt pleural effusion as compared with previous image
      • obliteration of Rt main bronchus
      • small nodular opacities over left lung
    • 2021-02-19 CT - lung/mediastinum/pleura
      • right middle lobe lung cancer with right lower lobe lung mets is suspected.
    • 2020-10-29 chest AP
      • extensive consolidation in Rt upper lobe and extensive ground glass opacity over Rt mid and lower lung zones
    • 2020-10-16 patho - urinary bladder TUR
      • histologic type: papillary urothelial carcinoma, invasive, with marked squamous differentiation
      • histologic grade: high-grade
      • tumor configuration: papillary
      • mascularis propria: present
      • microscopic tumor extension: tumor invades subepithelial connective tissue
      • VENTANA PD-L1 (SP142) assay for urothelial carcinoma: PD-L1 expression <5% IC
    • 2020-08-17 patho - urethra biopsy
      • urothelial carcinoma, low-grade.
      • muscularis propria not present.
  • surgical operation
    • 2020-01-16 Transurethral Resection of Bladder Tumor, TURBT
  • radiotherapy
    • 2021-10: 60Gy/30fx to the Rt hilar mets.
  • chemotherapy
    • 2021-11: VAC(vinblastin 3mg/m2, doxorubicin 22.5mg/m2, carboplatin 50mg)
    • 2021-05 ~ 2021-09: gemcitabine + carboplatin
    • 2020-11 ~ 2020-12: doxorubicin (intravesical)

==========

2022-03-01

  • hypotenstion 80/40 around 2022-03-01 01:00 ~ 02:00 was mitigated to 110/55 at 08:20 later the same day.
  • HGB 8.2 g/dL reported on 2022-02-28, EPO 5000U weekly could be considered if no contraindiction, until the reading backs to 11 g/dL.

2021-08-31

[lowering BP gently]

visiting the patient at around 16:45 on 2021-08-30, he did not complain of discomfort or unwellness these days, however he shared his experience of dizziness and fainting when SBP below 160mmHg since years ago. lowering blood pressure should be in a gentle way.

2021-08-30

[assessment]

  • Low HGB
    • EPO worked, RBC and HGB increased gradually, still some gap to normal range.
  • hypertenstion
    • drugs act as antihypertensive agents:
      • captopril (angiotensin converting enzyme inhibitor)
      • nicorandil (guanylyl cyclase stimulator; K channel activator)
      • amlodipine (Ca channel blocker)
    • for an ESRD patient, diurectics might not be indicated
    • sodium had fallen to the lower margin of normal range, no need to restrict Na intake.
    • interdialytic BP of <140/80 mmHg could be set an the target

[suggestion]

  • keep routine CBC monitoring as usual.
  • increase dialysis time might be considered if blood pressure remains high too long. ### 2021-08-26

[assessment]

  • this is an ESRD patient on hemodialysis with multiple comorbidities.
  • chemo drug dosing - source: https://pubmed.ncbi.nlm.nih.gov/30942181/
    • doxorubicin:
      • hemodialysis: consider administering 75% of the original dose.
    • carboplatin:
      • hemodialysis: carboplatin dose (mg) = target AUC x 25; administer on a nondialysis day, hemodialysis should occur between 12 to 24 hours after carboplatin dose.
  • hypochromemia
    • HGB 7.8g/dL reported on 2021-08-26 remains low for now.
    • epoetin beta 5000 unit SC QW3 prescribed since 2021-08-24.
  • not received chemo yet since this hospitalization.

[suggestion]

  • drugs prescribed for NSTEMI found in PharmCloud, refilled items listed as following, might be set as patient-carried ones into active medication if no contraindication…
    • famotidine 20mg QD
    • clopidogrel 75mg QD
    • aspirin 100mg QD
    • amiodarone QD
    • nitroglycerin ASORDER
    • nicorandil 5mg HS
    • amlodipine 5mg ASORDER
    • atorvastatin 20mg QD

700105459

220223

{SCC of tongue, cT4N1M0, s/p total glossectomy, right mandibular osteotomy, right marginal mandibulectomy, selective neck dissection, wide excision of malignant left lower gum SCC and marginal mandibulectomy, teeth extraction of #46, tracheotomy and free flap reconstruction}

[objective]

  • exam findings
    • 2022-02-10 CT - Lung/Mediastinum/Pleura
      • Impression: Bilateral lung meta, in progression.
      • S/p tracheal tube placement with its tip in place.
      • S/P NG tube placement.
    • 2021-10-25 Chect PA (Erect) view
      • Few nodular opacity projecting in the right upper and left lower lung is noted.
    • 2021-10-22 CT - Lung/Mediastinum/Pleura
      • Right upper lobe and left lower lobe lung meta.
      • Recurrent lymphadenopathy at right level II and level III and left parapharyngeal space.
    • 2021-10-19 CT - Neck
      • Status post tracheostomy.
      • Postoperative change in the oral cavity and neck, and post-irradiation change.
      • Suspect tumor recurrence or infection at left parapharyngeal space involving medial pterygoid muscle.
      • Necrotic nodal recurrence at right level II and left level III.
      • RUL nodule (2.1cm), suspect lung metastasis.
    • 2021-10-18 LN aspiration
      • Left neck mass: Positive for malignancy
        • Two wet smears show multiple dysplastic sqaumous cell clusters, compatible with metastatic squamous cell carcinoma.
    • 2021-08-16 Patho - oral cancer (wide excision + lymph node)
      • pathologic diagnosis
        • Tongue, total glossectomy - Moderately differentiated squamous cell carcinoma
        • Oral cavity, right retromolar region, right marginal mandibulectomy - Moderately differentiated squamous cell carcinoma
        • Oral cavity, left mandible region, wide excision - Severe dysplasia with ulcer
        • Pathology stage: pT4a(m)N0(if cM0); AJCC stage IVA
    • 2021-08-03 PET
      • Glucose hypermetabolism in the left aspect of the tonge with invasion to the mouth floor and left aspect of soft palate, compatible with malignancy involving these regions.
      • Glucose hypermetabolism in the some left neck level II, left submandibular and left level IV lymph nodes, compatible with metastatic lymph nodes.
      • Mild glucose hypermetabolism in some right neck level II and right submandibular lymph nodes. The nature is to be determined (inflammatory process? other nature?).
      • Glucose hypermetabolism in a focal area in the right aspect of mandible. The nature is to be determined (dental problem? other nature?).
      • Glucose hypermetabolism in the right shoulder and in the right pulmonary hilar region, compatible with inflammatory process.
    • 2021-08-02 Patho - Gingival/oral mucosa biopsy
      • Labeled as “left lateral tongue”, biopsy - squamous cell carcinoma.
      • IHC: P16(-, 0%); p40(+).
  • lab data
    • SCC
      • 2022-02-08 5.7ng/mL
      • 2021-08-04 6.1
      • 2021-08-03 5.8
  • surgical operation
    • 2021-08-13
      • Total glossectomy
      • R mandibular osteotomy
      • R marginal mandibulectomy
      • Selective neck dissection
      • Wide excision of malignant L lower gum SCC+ marginal mandibulectomy
      • Extraction of #46 (at anterior margin of skip L lower gum SCC)
      • Tracheotomy
      • Free left anterolateral thigh flap resurfacing to the intra-oral defect
      • Open reduction of mandible and internal fixation with reconstruction plates
  • radiotherapy
    • 2021-10-04 ~ 2021-11-22: bil. neck 50Gy/25fx. The tongue preOP tumor site: 66Gy/33fx. The gross LAPs: 70Gy/35fx
  • chemotherapy
    • 2022-02-03 ~ ongoing: 5-Fu + cisplatin + cetuximab, biweekly
    • 2021-10-27 ~ 2021-11-22: cisplatin weekly

700509991

220215

{gastric cancer, stage IIA, extra-capsular spread (ECS) positive}

[objective]

  • exam findings
    • 2021-12-24 Patho - stomach subtotal/total (tumor)
      • Diagnosis - Tumor, stomach, subtotal gastrectomy - Adenocarcinoma
      • AJCC Pathologic staging - pT2N1, if cM0, stage IIA
    • 2021-12-20 Patho - stomach biopsy
      • Diagnosis
        • Stomach, antrum GC side, s/p biopsy (A) - Adenocarcinoma.
          • IHC: Her2/neu: negative (score=1+).
        • Stomach, prepyloric antrum, s/p biopsy (B) - low grade dysplasia.
    • 2021-12-18 CT - abdomen, gastric filling with water
      • Gastric carcinoma
        • T2N1M0, stage IIA
  • surgical operation
    • 2021-12-23 radical subtotal gastrectomy with D2 lymph nodes dissection.
  • treatment
    • post-Op adjuvant CCRT with 5-FU 24 hr QD x 5 per wk x 6 plus R/T on 2022-02-14.

[assessment]

  • several targeted therapeutic agents, trastuzumab, pembrolizumab/nivolumab, and entrectinib/larotrectinib have been approved by the FDA for use in gastric cancer.
    • trastuzumab is based on testing for HER2 overexpression.
    • pembrolizumab/nivolumab are based on testing for MSI by PCR or NGS/MMR by IHC, PD-L1 immunohistochemical expression, or high tumor mutational burden (TMB) by NGS.
    • FDA granted approval for the use of select TRK inhibitors for NTRK gene fusion-positive solid tumors.
  • when limited tissue is available for testing, or the patient is unable to undergo a traditional biopsy, sequential testing of single biomarkers or use of limited molecular diagnostic panels may quickly exhaust the sample. in these scenarios, comprehensive genomic profiling via a validated NGS assay performed in a CLIA-approved laboratory may be used for the identification of HER2 amplification, MSI status, MMR deficiency, TMB, and NTRK gene fusions. the use of IHC/ISH/targeted PCR should be considered first followed by additional NGS testing as appropriate.
  • no drug allergy recorded in database, no issue found with current medication.

700926086

220215

[objective]

  • Exam findings
    • 2022-02-11 CT
      • Prior CT identified few small LNs at para-aortic space and bil. inguinal regions show stationary.
    • 2021-11-08 MRI
      • Cervical spondylosis with diffuse spinal canal stenosis, cord compression and neuroforaminal narrowing, esp C3-4 with compressive myelopathy.
    • 2021-10-29 PET
      • Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm and bone marrow may show this picture (stage IV).
      • Increased FDG uptake in the soft tissues around bilateral hips. Inflammation is more likely.
    • 2021-10-20 Patho - bone marrow biopsy
      • Diagnosis
        • Bone marrow, iliac, biopsy — Lymphoma, B cell type
        • IHC:
          • CD3 and CD20: a predominant small sized B lymphoid cells subpopulation;
          • CD138: 50%;
          • kappa and lambda: approximately 2:1.
          • bcl-2 (+, 90%) bcl-6 (-) (of the nucleated cells).
          • Serum immunoglobin levels show evelated both IgG and IgM levels.
          • KI-67: marked variation from areas to areas ranging 5% to 60% and averaing 20% to 25%.
      • Microscopic
        • Section shows piece(s) of bone marrow with 100 % cellularity a mixed small lymphocytes subpopulation and plasmacytoid cell subpupulation.
        • The bone marrow findings in conjunction with serum immunoglbulin levels is suggestive of B cell lymphoma, small B cell type, or lymphoplasmacytoid cell type. Probably a polyclonal Waldemstrom-like lymphoma.
    • 2021-07-24 CT
      • Minimal opacity over B6 (superior segment) of right lower lobe, right middle lobe, and left upper lobe is found.
      • Small lymph nodes at bilateral axillary, supraclavicular and abdominal paraaortic region.
    • 2020-10-23 MRA - Brain
      • Mild general brain atrophy. Subcortiacl arteriosclerotic encephalopathy.
    • 2020-10-05 Clinical Dementia Rating (CDR)
      • Score 1
    • 2020-09-19 CT
      • Small LNs at retroperitoneum, bil. axillary and bil. inguinal regions.
    • 2020-09-01 Patho - bone marrow biopsy
      • Diagnosis
        • Bone marrow, iliac, biopsy - Proliferation of lymphoplasmacytic cells.
        • IHC:
          • CD20 (80-90%);
          • CD138 (weak intensity, approximately 50%);
          • kappa and lambda: no predominant subpopulation.
          • CD3: <10%. (of the nucleated cells).
        • The possibility of lymphoplasmycitc lymphoma/ Waldenström macroglobulinemia (WM) cannot be excluded.
      • Microscopic
        • Section shows one piece of bone marrow with 90% cellularity and M:E ratio of approximately 5:1.
        • Three cell lineages are present with a predominant of leukocytes.
  • Chemotherapy
    • 2021-11-16 ~ up to now: R-CVP (rituximab, cyclophosphamide, vincristine, prednisone)

[assessment]

  • the most updated NCCN clinical practice guidelines for B-Cell Lymphomas (evidence blocks, version 5.2021 - Sep 22, 2021) suggests small cell testing panel: CD5, CD10, CD21, CD23, cyclin D1, BCL2, BCL6, Ki-67, CD11c, CD25, CD103 for differential diagnosis. not all items found in patho records.
  • lab data reported on 2022-02-14 revealed no abnormality of liver and kidney functions.
  • CT on 2022-02-11 showed stable LNs at para-aortic space and bil. inguinal regions.
  • involved-site RT (ISRT) might not be indicated for the stage IV disease.
  • the patient is on R-CVP regimen which is recommend in the guidelines. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) might be an alternative.
  • no drug allergy recorded in database. no issue with current medication.

701349358

220215

[objective]

  • exam findings
    • 2021-12-02 Patho - stomach subtotal/total (tumor)
      • stomach, antrum, subtotal gastrectomy - signet-ring cell carcinoma
      • small intestine, duodenum, subtotal gastrectomy - signet-ring cell carcinoma, by direct invasion
      • omentum, omentectomy - negative for malignancy
      • lymph node - signet-ring cell carcinoma, metastatic
      • pT2N3b(if cM0), pStage IIIB
      • gross configuration: for advanced carcinoma (Borrmann classification): Type III
        • ulcerated with poorly defined infiltrative margins
      • histologic type: adenocarcinoma, Lauren classification of adenocarcinoma: diffuse type
      • histologic grade: G3 - poorly differentiated, undifferentiated
      • tumor extension: tumor invades the muscularis propria
      • lymphovascular Invasion, perineural invasion, intestinal metaplasia, high-grade dysplasia, polyps: absent
    • 2021-11-30 Patho - stomach biopsy
      • stomach, antrum, biopsy — signet-ring cell carcinoma
      • IHC: CK(+), Her-2/neu (Ab)(-).
    • 2021-11-30 Esophagogastroduodenoscopy
      • highly suspected gastric cancer, antrum, Borrmann type 3, sp biopsy
    • 2021-11-29 CT - abdomen gastric filling with water
      • T2N2M0, stage IIA
  • radiotherapy
    • 2022-02 Adjuvant RT to anastomosis and regional lymphatics for 4500cGy/25fx is suggested for locoregional control.
  • chemotherapy
    • 2022-02-14 starts 5-FU

700276060

220209

{Thalidomide/Dexamethasone Interaction}

Dexamethasone might enhance the dermatologic adverse effect and/or thrombogenic effect of Thalidomide.

Consider using venous thromboembolism prophylaxis in patients with multiple myeloma who are receiving both thalidomide and dexamethasone, particularly if the patient is newly diagnosed or has other risk factors for thromboembolism. Low-molecular-weight heparin or warfarin (at INR of 2.0-3.0) have been proposed as reasonable prophylactic agents. Regarding the potential dermatologic interaction between thalidomide and dexamethasone, monitor for any evidence of dermatologic events, particularly maculopapular or erythematous rash. If evident, discontinuation of drug therapy or dosage reduction may be required.

701023219

220208

  • Lab findings
    • MRI - nasopharynx
      • Right NPC with neck LAPs. T2N3M0 stage IVA.
    • 2021-08-04 Patho - nasopharyngeal/oropharyngeal biopsy
      • Nasopharyngeal carcinoma, non-keratinizing and poorly differentiated
      • IHC: CK(+).
    • 2021-08-04 Nasopharyngoscopy
      • rt np tumor.
    • 2021-07-29 Patho - lymphnode biopsy
      • Labeled as “right neck”, biopsy - Lymph node with round blue cell tumor, metastatic.
      • IHC: CK(+), poorly differentiated carcinoma. EBV(-), p16(-).
      • Please check nasopharynx, oropharynx, supra- and sub-glottis first.
  • Surgical operation
    • 2021-08-17 removing an enlarged lymph node over right posterior neck.
  • Regimen
    • 2021-11 ~ ongoing Cisplatin + Fluorouracil
    • 2021-08 ~ 2021-10 Cetuximab
  • Radiotherapy
    • 2021-08-20 ~ 2021-10-11
      • 5000cGy/25 fractions of the nasopharyngeal to bilateral neck,
      • 6000cGy/30 fractions of the nasopharyngeal tumor and involved nodal,
      • 7000cGy/35 fractions of the reduced nasopharyngeal tumor and involved nodal lesions.

700731496

220128

{possible drug interaction: Dasatinib / Histamine H2 Receptor Antagonists}

[objective]

  • current medication includes:
    • Sprycel (Dasatinib 50mg) 1# PO QD
    • Ulstop (Famotidine 20mg) 1# PO BID

[assessment]

  • Histamine H2 Receptor Antagonists might decrease the absorption of Dasatinib.
  • Coadministration of H2RAs and Dasatinib may reduce dasatinib concentrations and efficacy.
  • Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required.
  • The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.
  • references:
    • Takahashi N, Miura M, Niioka T, Sawada K. Influence of H2-receptor antagonists and proton pump inhibitors on dasatinib pharmacokinetics in Japanese leukemia patients. Cancer Chemother Pharmacol. 2012;69(4):999-1004.
    • Sprycel (dasatinib) [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; September 2016.
    • Eley T, Luo FR, Agrawal S, et al. Phase I study of the effect of gastric acid pH modulators on the bioavailability of oral dasatinib in healthy subjects. J Clin Pharmacol. 2009;49(6):700-709.
    • Matsuoka A, Takahashi N, Miura M, et al. H2-receptor antagonist influences dasatinib pharmacokinetics in a patient with Philadelphia-positive acute lymphoblastic leukemia. Cancer Chemother Pharmacol. 2012;70(2):351-352.
    • Koutake Y, Taniguch J, Yasumori N, et al. Influence of proton pump inhibitors and H2-receptor antagonists on the efficacy and safety of dasatinib in chronic myeloid leukemia patients. Int J Hematol. 2020;111(6):826-832.

[suggestion]

  • Antacids should be taken 2 hours before or after dasatinib administration if acid-reducing therapy is needed.

701032519

220127

{marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)}

[objective]

  • Exams
    • 2022-01-11 Whole body PET scan
      • Mild glucose hypermetabolism in some focal areas in bilateral lung fields. Residual lymphoma should be considered. However, in comparison with the previous study on 2021/08/19, the previous glucose hypermetabolic lesions in bilateral lung fields are either less evident or disappeared.
      • Glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation is more likely.
      • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2022-01-04 CT - Lung/Mediastinum/Pleura
      • post op change in LUL
      • regression nodular lesions of both lungs as compared with CT on 2021/8/18.
    • 2021-08-20 Patho
      • Bone marrow, iliac, biopsy - Negative for malignancy
      • Microscopically, it shows 15% of cellularity, prsence of trilineage cellular component and some megakaryocytes.
      • IHC: CD20(-), CD34(-), CD117(-), CD3(-), CD138(-), MPO(+), CD71(+).
    • 2021-08-19 Whole body PET scan
      • Glucose hypermetabolism in multiple focal areas in bilateral lung fields, compatible with lymphoma.
      • Glucose hypermetabolism in some mediastinal lymph nodes. The nature is to be determined (inflammation? other nature?).
      • Increased FDG accumulation in the left neck muscle, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
    • 2021-08-18 CT - ABD - whole abdomen, pelvis
      • Lymphoma s/p treatment show partial response.
    • 2021-07-26 Patho
      • Lung, right upper lobe, CT-guide biopsy - Extranodal marginal zone lymphoma of MALT type with amyloidosis
      • The immunohistochemical analysis shows that these cells are positive for CD20, bcl-2, and CD43, and negative for CD3, BCL6, and CD23. CD138 highlights increased plasma cells, but kappa and lambda are inconclusive. CD68 is positive for the foreign-body giant cells. CK highlights lymphoepithelial lesions.
      • Taken together, extranodal marginal zone lymphoma of MALT type with amyloidosis is considered.
    • 2020-10-13 Patho
      • Lung, RUL, CT-guide biopsy - interstitial fibrosis and lymphoplasma cells infiltration
      • The immunohistochemical stains of CD3, CD20, CD138, and Ki-67 show mixed lymphoid and plasma cells population with lymphoid follicles.
      • The immunohistochemical stain of CK reveals no invasive tumor. No amyloid deposition is seen.
  • Surgery
    • 2019-12-30
      • One nodular lesion was noted over left apex of LUL, another one nodule was noted over LUL, size about 0.8cm and 1.5 cm.
      • Frozen section: benign lesion.
  • Regimen
    • 2021-08 ~ ongoing R-CVP (R-COP)
      • Rituximab 375mg/m2 IV D1
      • Cyclophosphamide 750mg/m2 IV D1
      • Vincristine 1.4mg/m2 IV D1
      • Prednisone 40mg/m2 PO D1-5
      • repeat every 21 days for a max of 8 cycles

==========

2022-01-27

  • This 80-year-old male patient was diagosed with extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) 2021 summer, being receiving R-CVP since 2021-08 and partial response was seen in early Jan 2022 based on CT and PET images.
  • R-CHOP, R-CVP (which is being usd now), Bendamustine + Rituximab, are candidate regimen as first-line therapy. no issue with current regimen.
  • Consolidation with rituximab 375mg/m2 one dose every 8~12wk for up to 24 mo could be an optional extended therapy for future consideration.

2022-01-10

COPD is listed as one of the diagnoses (but not in current problem list) in this hospitalization, however no corresponding medication prescribed yet.

Some bronchodilators such as beta agonists, antimuscarinic agents, or methylxanthines might be considered later after other acute symptoms mitigated.

700560024

220125

{marginal zone lymphomas}

[objective]

  • lab findings
    • 2021-09-14 CT - Lung/Mediastinum/Pleura
      • Impression: lymphadenopathy in the axillary and abdominal regions, involving both sides of diaphgrams.
    • 2021-09-07 Patho - lymphnode biopsy
      • Lymph node, axillary, left, biopsy - Small B-cell lymphoma, compatible with marginal zone lymphoma.
        • Immunophenotyping: CK(-), CD3(-), CD20(+), CD5(-), CD23(+), CD43(-), CD10(-/+), Cycline D1(-).
    • 2020-11-20 Patho
      • Stomach, antrum, PW, biopsy - Suspicious lymphoid infiltrate, probably extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) with Helicobacter pylori infection.
        • IHC, the small lymphoid cells: CD3(-), CD20(+), BCL2(+), CD5(-), CD10(-), and CD43(-).
      • Stomach, low body, GC side, biopsy - Suspicious lymphoid infiltrate, probably extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) with Helicobacter pylori infection.
        • IHC, the small lymphoid cells: CD3(-), CD20(+), BCL2(+), CD5(-), CD10(-), and CD43(-).
  • treatment
    • 2021-10 ~ ongoing - R-CHOP

[assessment]

  • first-line therapy regimens for marginal zone lymphomas could be:
    • CHOP(cyclophosphamide, doxorubicin, vincristine, prednisone) + Rituximab
    • CVP(cyclophosphamide, vincristine, prednisone) + Rituximab
    • Bendamustine + Rituximab
  • the patient is receiving R-CHOP without much intolerance.
  • no issue with current medication.

700149178

220124

This 92-year-old woman diagnosed by NTUH in 2021 Dec wtih advanced ascending colon cancer with lung, paraaortic LN, peritoneal carcinomatosis, cT4aN2bM1c, stage IVC.

Take into account of the patient’s age, intensive therapy might not be most appropriate, a vanilla regimen like FOLFOX could be a candidate for systematic treatment.

KRAS, NRAS, BRAF, HER2, MSI/MMR, NTRK fusion, dihydropyrimidine dehydrogenase test might be ordered optionally if related data from NTHU is not anticipated.

700191057

220124

{lung cancer with bone and brain metastasis}

[lab data]

  • PD-L1(28-8) 2021-04-08 TC < 1%
  • ROS1 2021-03-24 not detected
  • PD-L1(22C3) 2021-03-22 TPS < 1%
  • EGFR 2021-03-19 G719X not detected
  • EGFR 2021-03-19 Exon19 deletion not detected
  • EGFR 2021-03-19 S768I not detected
  • EGFR 2021-03-19 T790M not detected
  • EGFR 2021-03-19 Exon20 insertion not detected
  • EGFR 2021-03-19 L858R not detected
  • EGFR 2021-03-19 L861Q not detected
  • ALK IHC 2021-03-18 negative

[exam findings] (not completed)

  • 2023-05-04 MRI - brain
    • Known a case of lung cancer with brain metastasis. As compared with prior MRI (2023/03/08), disseminated leptomeningeal metastasis of whole cerebrum. Metastatic lesions over cerebellum and both temporal lobes are in worse condition.
    • Severe paranasal sinusitis.
    • Left mastoiditis.
  • 2023-05-02 CXR
    • Atherosclerotic change of aortic arch
    • Diffuse Bony metastases.
  • 2023-03-14 MRI - C-spine
    • Several mass lesions within C4, C5, C6 and T1 vertebral bodies, compatible with metastases.
    • No actual disk protrusion or cord compression.
    • The cervical spinal cord shows normal size and signal intensity without evidence of compressive edema, ischemia or myelomalacia. There is no extrinsic compresson of the cord.
    • The neural foramina of the cervical spine are patent. No impingement is seen.
  • 2023-03-09 CT - chest
    • Indication: Lung cancer with bone and brain mets
    • Chest CT with and without IV contrast ehnancement shows:
      • s/p left upper lobe op.
      • Minimal atelectatic change at bilateral lower lobes is found.
      • S/p port-A placement with its tip at Superior vena cava
      • Non-specific lymph nodes are found at bilateral paratracheal region.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • s/p cholecystectomy.
    • Imp:
      • s/p left upper lobe op.
      • Diffuse bone meta.
      • Non-specific lymph nodes at bilateral paratracheal region.
  • 2023-03-08 MRI - brain
    • r/o leptomeningeal metastasis in the bilateral posterior cranial fossa.
  • 2023-03-01 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022-12-05, all of above-mentioned bone lesions are old and show stationary or less evident, and no new lesion of increased tracer uptake is noted in this study, indicating metastatic bone disease with partial response to current therapy.

[immunochemotherapy]

  • 2022-01-21 ~ ongoing
    • Nivolumab + Ipilimumab + Pemetrexed + Carboplatin
      • Nivolumab 3mg/kg D1 Q3W
      • Ipilimumab 1mg/kg D1 Q6W
      • Pemetrexed 500mg/m2 D1 Q3W*2cycles
      • Carboplatin AUC 5~6 D1 Q3W*2cycles
  • 2021-10-22 ~ 2022-01-04
    • Nivolumab + Ipilimumab
      • Nivolumab 3mg/kg D1 Q3W
      • Ipilimumab 1mg/kg D1 Q6W
  • 2021-03-25 ~ 2021-10-21
    • Gefitinib 250mg QD

[consultation]

  • 2021-02-17 Hemato-Oncology
    • Q
      • for suspect multiple myeloma, metastases
      • This 49-year-old female was Dx (1) Leukocytosis, suspect intra abdominal infection (2) Suspect multiple myeloma, metastases (3) Hypertension (4) Fracture of 7th ribs in 2020-12. This time, she was admission because bilateral lower leg edema for two days. She complained for lower back pain while mobile and right back sorenss for 3 months and subside while lying down. She has suffered from fracture of left 7th rib and right little toe pain and local redness. According to the patient, she has visited Ortho OPD and Rheumatology OPD for the recurrent multiple joint pain. She came to our ER. CT image revealed retroversion of uterus with tumors (up to 6.3cm) suspected myomas and Multiple osteolytic lesions at bony structures. DDX: multiple myeloma, metastases. Please evaluation her condition by your expertise. Thank you very much.
    • A
      • Patient examined and Chart reviewed. A case of multiple bony destruction is noted. I am consulted for the possible etiolgy.
      • My suggestions:
        • Complete CT scan work-up e.g., Chest CT, to rule out CEA-elevated lung cancer or CEA/CA153-elevated breast cancer
        • Please survey breast conditin, using breast sono and/or mammography to rule out CEA/CA153-elevated breast cancer
        • Please check Protein EP/IFE, kappa/lambda chain to rule out myelopma or light chain disease
        • Please perform EGD and colonoscopy to rule out CEA-elevated GI cancer
        • If no clue from the afroementioned examinations, bone marrow biopsy is mandatory.

==========

2022-01-24

  • pembrolizumab is approved for NSCLC with PD-L1 expression levels ≥ 1%, it is not the case here.
  • for NSCLC with no specific mutations, if progression on PD-1/PD-L1 inh, using a PD-1/PD-L1 inh might not be recommended.
  • there is no issue found in current medication.

700974194

220124

{drug identification}

requesting drug identification for 6 items.

the 4 identified items has been shown as following while the other 2 items still remain unknown: - Megajohn - megestrol 160mg - Kentamin - thiamine 50mg, pyridoxine 50mg, cyanocobalamin 500mcg - Romicon-A - lysozyme 20mg, dextromethorphan 20mg, cresolsulfonate 90mg - Olmetec - olmesartan medoxomil 20mg

these drugs will be sent back to ward by an in-hospital porter.

701358139

220124

[objective]

This is a patient diagnosed by TSGH with poorly differential gastric adenocarcinoma with carcinomatosis and metastatic lymphadenopathy and bone metastasis, cT4aN3aM1, stage IV, seeking for second opinion on 2022-01-21.

  • Lab readings:
    • 2022-01-22 Urine: Bacteria 2+
    • 2022-01-22 Abdomen - standing diaphragm: Ascites is highly suspected.
    • 2022-01-22 Chest PA - erect view:
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
      • Discoid atelectasis in LLL of the lung is suspected.
    • 2022-01-21 Blood K 3.0mmol
    • 2022-01-21 Blood gas - vein:
      • PO2 65mmHg
      • O2 Saturation 92%
  • Medication
    • fluid balance, hypokalemia
      • NAKO No.5
      • KCl inj
      • Radi-K
      • Spironolactone

[Assessment]

  • Empirical ABX might be considered if applicable based on symptoms prior to culture outcome.
  • The following tests could be optionally ordered for future therapy choice if no related data gathered from TSGH.
    • Microsatellite Instability (MSI) or Mismatch Repair (MMR)
    • PD-L1
    • HER2, high tumor mutation burden, NTRK gene fusion
  • Mirabegron (beta-3 agonist) might diminish the antihypertensive effect of Doxazosin (alpha-1 blocker).
  • The mirabegron prescribing information reports dose-dependent increases in blood pressure with use. In healthy volunteers mirabegron (at doses of up to 50 mg) produced mean maximum increases in systolic/diastolic blood pressure of 3.5/1.5 mm Hg versus placebo. However, in overactive bladder (OAB) patients, including those with pre-existing hypertension, receiving a maximum dose of mirabegron 50 mg, the systolic/diastolic blood pressure was only 0.5 to 1 mm Hg greater than placebo. OAB patients infrequently reported worsening of pre-existing hypertension with mirabegron. Both systolic and diastolic blood pressure increases were reversible with the discontinuation of mirabegron.
  • Lab data serum potassium 3.0mmol/L reported on 2022-01-24 showed the reading below normal range (3.5~5.1), KCl inj and potassium sparing diuretic Spironolactone have been prescribed.

701164753

220120

  • Diagnosis: Splenic flexure colon obstruction and massive ascites suspected carcinomatosis status post T-loop colostomy on 2021-08-27.

  • 2021-08-30 Patho - omentum tumor, extensive resection

    • Omentum, frozen section + end transverse colostomy - Metastatic adenocarcinoma.
  • 2021-08-25 Patho - colorectal polyp

    • IHC: CK(+), CK7(-), CK20(-), CDX2(+), CD56(-), LCA(-), PSA(-), and AMACR(-).
      • The morphology and immunohistochemical stains are not typical for colonic adenocarcinoma.
      • The CDX2 is positive, in favor of GI tract, pancreas, and biliary tract.
      • The PAS and AMACR are negative, so disfavor prostate origin.
      • The CD56 and LCA are negative, so disfavor neuroendocrine tumor and lymphoma.
      • Please correlate with the clinical presentaion, and image study, such as PET or gastroscope, for tumor origin.
  • Medication

    • 2021-09 ~ gogoing - FOLFIRI (plus bevacizumab since 2021-10)

701313105

220120

  • Lab
    • 2021-08 Patho - overy tumor
      • IHC: CK7 (+), CK20 (-), p53 (-), Napsin-A(-), WT-1 (-).
  • Medication
    • 20210823 ~ ongoing - Paclitaxel, Carboplatin

700042050

220119

[objective]

  • lab data:
    • Na 2022-01-18 125mmol/L
    • K 2022-01-18 2.7mmol/L
    • Mg 2022-01-18 1.8mg/dL
    • Free T4
      • 2021-10-15 1.3ng/dL
      • 2021-08-17 0.95ng/dL
    • TSH
      • 2021-10-15 14.46uIU/mL
      • 2021-08-17 0.117uIU/mL
  • medication
    • Radi-K (potassium gluconate)
    • MgO
    • Eltroxin (levothyroxine)

[assessment, suggestion]

  • In addition to current Radi-K administration, the low serum K might be induced by low serum Mg, bioavailability of Mg from oral MgO is around 5~10%, MgSO4 Inj might be considered to pump up serum Mg more rapidly.
  • Last thyroid hormone related lab records were taken more than 3 months ago, there is no updated data to follow up the hyped TSH, which could be ordered if no contraindication.

700073358

220119

  • no drug allergy recorded in database.

  • CBC reported on 2022-01-18 showed items below normal ranges:

    • WBC 2.96*10^3/uL
    • RBC 3.47*10^6/uL
    • HGB 11.8g/dL
  • no liver or kidney dysfuncion shown in recent lab data.

  • the drugs prescribed at neurology OPD have been included in active medication, no issue found.

701011322

220119

  • CBC reported on 2022-01-18 showed items below normal ranges:

    • WBC 3.17*10^3/uL (Neutrophil 65%)
    • RBC 3.27*10^6/uL
    • HGB 8.6g/dL
    • PLT 73*10^3/uL
  • no drug allergy recorded in database.

  • no liver or kidney dysfuncion shown in recent lab data based on AST, ALT, BUN, Creatinine, eGFR.

  • no issue found in active medication.

700145757

220118

[objective]

Lab data - Free T4 - 2022-01-14 2.26ng/dL (normal 0.58~1.35) - 2021-10-05 1.94ng/dL - TSH - 2022-01-14 0.027uIU/mL (normal 0.38~5.33) - 2021-10-05 <0.005uIU/mL

PE - body weight - 2022-01-14 65kgw - 2022-01-09 68kgw

Medication - Eltroxin (levothyroxine 50mcg/tab) #1 BIDAC

[assessment]

  • The patient is diagnosed with nontoxic goiter.
  • Thyroid dysfunction - If the goiter is due to Hashimoto’s thyroiditis or severe iodine deficiency, patients may have symptoms of hypothyroidism (eg, fatigue, constipation, cold intolerance). If due to multinodular goiter (with autonomy) or Graves’ disease, patients may have symptoms of hyperthyroidism (eg, palpitations, dyspnea on exertion, unexplained weight loss).
  • Low TSH, high free T4, weight loss reported.

[suggestion]

  • Eltroxin tapered to QDAC or Q2DAC and then test TSH, free T4 one week later to check the trend.

700712820

220112

  • 2022-01-11 CT: Brain
    • Imp: Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2021-10-27 MRA: Brain
    • Imp: Brain metastases. General brain atrophy. Hydrocephalus. Leukoaraiosis.
  • 2021-08-17 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest multiple bone metastases.
  • 2021-08-16 PD-L1 (SP142)
    • Tumor type: formalin fixed paraffin embedded tissue block - peritoneal and omental tumor (lung adenocarcinoma metastasis)
    • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result
      • Tumor cell (TC) staining assessment:
        • TC category: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): 0%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC < 1%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 0%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2021-08-11 Pathology - peritoneum biopsy
    • Labeled as “diffuse seeding tumor over peritoneum and omentum”, biopsy — adenocarcinoma.
    • IHC stains:
      • CK7 (+), CK20 (-): disfavor gastrointestinal origin;
      • PAX-8 (-), WT-1 (-): disfavor ovarian origin;
      • TTF-1 (+): comaptible with pulmonanry origin.
  • 2021-08-10 Cell block - 50 cc orange cloudy pleural effusion
    • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with pulmonary adenocarcinoma.
  • 2021-08-09 Surgery - laparoscopic peritoneal tumor biopsy
    • Finding: multiple seeding tumors over liver surface, omentum, peritoneum, and mesentary

==========

2022-01-12

[hyponatremia, hypoosmolality]

objective

  • lab data
    • 2022-01-12 blood osmolality 254mOsm/Kg (normal 275~295)
    • 2022-01-12 blood sodium 119mmol/L (normal 136-145)
  • body weight
    • 2022-01-11 54kgw
    • 2022-01-04 58kgw
  • medication
    • 3% NaCl 300mL IVD QD
    • Saline 0.9% 500mL IVD QD

assessment

suggestion

  • no issue found in current medication.
  • recheck serum sodium as regular until problem solved.
  • might need to evaluate etiology of depletion hypoosmolality.

2021-08-24

[initial presentation]

  • 2021-01-22 left back pain for 1 year -> congenital spondylolisthesis
  • 2021-07-09 left flank region pain in recent days, AZ covid-19 vaccination on 2021-06-21.
  • 2021-07-16 remained abdominal pain, multiple, no obvious tenderness, migratory abdominal pain, radiating to perineum region on left, tingling sensation.

[definite diagnosis & disease extent]

  • 2021-07-16 CT - whole abdomen, pelvis:
    • carcinomatosis is suspected.
    • metastases on both hepatic lobes are suspected.
    • tumor seeding in left CP angle pleura is suspected.
      • lung cancer 1.7 cm in LLL of the lung is suspected.
  • 2021-07-20 abdominal ultrasound:
    • hepatic tumor, multiple, probably metastatic tumor
    • dilated CBD, ascites, left pleural effusion
  • 2021-07-22 CT - lung/mediastinum/pleura
    • left upper lobe tumor, suspected lung cancer T2N2Mx
    • cancerous peritonitis and liver mets, suspected GI origin.
  • 2021-07-22 lab:
    • AFP 4.4 ng/mL WNL
    • CEA 107ng/mL > ULN
    • CA125 474U/mL > ULN
    • CA199 65U/mL > ULN
    • CA153 114U/mL > ULN
    • SCC 1.1ng/mL WNL
  • 2021-07-23 cytology - ascites:
    • abundant high-grade atypical cells with nuclear hyperchromasia, pleomorphism and prominent nucleoli.
  • 2021-07-26 colonoscopy:
    • colon polyp, suspected adenoma, ascending colon, s/p cold snare polypectomy.
    • diverticula, cecum and ascending colon.

[plan & treatment]

[effect & side effect]

[ongoing problem]

700527901

220111

{Diffuse Large B Cell Lymphoma}

[objective]

  • MRI reported on 2021-12-28
    • Tonsillar fossa, 2cm < size < 4cm, no regional nodal metastasis, T2N0M0
  • patho reported on 2021-12-30 - right tonsil biopsy
    • Diagnosis: diffuse large B cell lymphoma
    • IHC: CD20(+), CD3(-), CD10(-), CD30(-), CK(-), Bcl-2(+), Bcl-6(+, focal), C-MYC(+, 30-40%), Ki-67 70-80% for tumor
  • LDH reported on 2022-01-10 136U/L (normal 140~271)

[assessment]

  • B-cell lymphomas with translocations of MYC and BCL2 and/or BCL6 (double-/triple-hit lymphoma), elevated LDH not seen, bone marrow and CNS involvement not checked.

[suggestion]

  • no drug allergy recorded in database, no issue found in active medication.
  • if localized high-grade B-cell lymphomas is confirmed, then consolidative ISRT might be considered.

700766397

220111

CT and MRI on 2022-01-05 suggested possible malignant tumor in the right adrenal gland measuring 8.2 x 10 x 9 cm.

Chromogranin A 918ng/mL, ACTH < 5g/mL

lab data in early Jan 2022 did not backup hyperaldosteronism, hypercortisonlemia (i.e. both in normal range).

hypertenstion and/or tachycardia might have been mitigated by Concor (bisoprolol), higher readings of blood sugar (since mid Dec 2021) might have been reduced by Galvus Met (vildagliptin + metformin), these symptoms could be caused by neuroendocrine tumors.

701356176

220110

[Objective]

Lab data reported on 2022-01-10 and some prescribed medication: - CRP 9.17mg/dL (normal <1), WBC 166*10^3/uL (normal 3.9~10.6) <= Tapimycin (Piperacillin + Tazobactam) - Blood Uric Acid 16.3mg/dL (normal 4.4~7.6) <= Fasturtec (Rasburicase) - Calcium 4.04 mmol/L (normal 2.2~2.65) <= Miacalcic (Calcitonin) - Magnesium 1.4mg/dL (normal 1.9~2.7) - Triglyceride (TG) 524mg/dL (normal <150), HDL-C 5mg/dL (normal >40) - Benz(BZO) intoxication positive (normal negative)

[Assessment/Suggestion]

  • MgO might be considered for hypomagnesemia.
  • Flumazenil might be considered for benzodiazepine intoxication.
    • Unable to access PharmaCloud now, might need to find out why intoxication happened.
  • Statins might be considered for hypertriglyceridemia later after acute symptoms been controlled.

700404241

220107

[Objective]

  • Adenocarcinoma of descending-sigmoid colon with partial obstruction status post laparoscopic left hemicolectomy on 2021-10-13, pT3N1aM0, pStage IIIB.
    • IHC stains: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+) based on colon segmental resection, reported on 2021-10-20.
  • Chronic viral hepatitis B without delta-agent.
  • Lab data reported on 2022-01-04 showing basically normal readings at CBC, WBC, ALT, AST, bilirubin total, creatinine, eGFR, and slightly elevated BUN 30mg/dL.
  • All RAS and BRAF mutation not detected, reported on 2021-11-03.

[Assessment]

  • FOLFOX 3-6 mo or CAPEOX 3 mo is preferred as adjuvant treatment for T3N1M0 colon cancer patients. This patient is now on FOLFOX course.
  • Nivolumab or Pembrolizumab might not be preferred for this pMMR patient.
  • Panitumumab or Cetuximab might be applicable as RAS and BRAF proved wildtype for the left-sided patient.
  • HER2, NTKR data not found yet.
  • Hepatitis B virus might reactivate in the setting of chemotherapy. Baraclude (Entecavir) has been prescribed.

[Suggestion]

  • No issue found in active medication. Keep tracking CEA, CT as regular.

700098157

220106

High Serum glucose 235mg/dL (2022-01-05), Lactic Acid 4.9mmol/L (2022-01-06), NAKO NO.5 500mL IVD BID and Saline 500mL IVD QD are prescribed.

High CRP 13.47mg/dL (2022-01-05), Procalcitonin (PCT) 8.37ng/mL (2022-01-06) suggest (probable bacterial) infectious process with systemic consequences. Tapimycin and Targocid are prescribed.

700753433

211019

{drug identification}

requesting drug identification for 7 items.

the 3 identified items has been shown as following while the other 4 items still remain unknown:

  • Utapine F.C. Tablet (quetiapine fumarate 25mg) - bipolar disorder, schizophrenia

  • Zoloft F.C. Tablet (sertraline hydrochloride 50mg) - major depressive disorder (unipolar), obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, social anxiety disorder

  • Anxiedin Tablet (lorazepam 0.5mg) - anxiety

these drugs will be sent back to ward by the in-hospital porter.

700029300

210930

{drug identification}

requesting drug identification for 13 items.

the 9 identified items are listed as following, however, the other 4 items still remain unknown:

  • Galvus Met (Metformin HCl 850mg, Vildagliptin 50mg)
  • Betmiga (Mirabegron 25mg)
  • Avodart (Dutasteride 0.5mg)
  • Mequitine (Mequitazine 5mg)
  • Co-Tareg (Valsartan 80mg, Hydrochlorothiazide 12.5mg)
  • Nonin (Glimepiride 2mg)
  • Bokey (Aspirin 100mg)
  • Crestor (Rosuvastatin 10mg)
  • Levozine (Levocetirizine 5mg)

these drugs will be sent back to ward by the in-hospital porter.

700043762

210928

{potential drug interactions, vitamin supplement}

[objective]

  • items listed in active medication including:
    • emetrol (domperidone 10mg/tab) 2 tab PO TIDAC
    • rivotril (clonazepam 0.5mg/tab) 1 tab PO HS
    • keppra (levetiracetam 100mg/ml) 3 ml PO BID
    • calquene (acalabrutinib 100mg) 1 tab PO Q12H
  • lab data reported on 2021-09-25
    • gastric juice OB 3+
    • RBC 2.78*10^6/mL
    • HGB 9.8g/dL
    • MCV 101fL

[assessment]

  • there are drugs in active medication might have potential interactions:
    • acalabrutinib <> lansoprazole
      • PPI might decrease the serum concentration of acalabrutinib.
      • with the long-lasting effect of PPIs, separation of doses might not eliminate the interaction.
      • acalabrutinib AUC was decreased by 43% when co-administered with the PPI omeprazole (40 mg for 5 days) according to studies of healthy subjects. this decreases in acalabrutinib concentrations might reduce acalabrutinib activity, so the acalabrutinib labeling recommends that if treatment with a gastric acid reducing agent is required, a histamine-2 receptor antagonist (H2RA) or an antacid should be considered, with separation of administration to minimize the likelihood of a significant interaction.
    • clonazepam <> levetiracetam
      • CNS depressants may enhance the adverse/toxic effect of other CNS depressant
  • emetrol (domperidone) dosing
    • 10mg x 3 times (max) a day stated in package insert, however, prescirbed daily dose is 60mg.
  • suspected GI bleeding
    • somewhat anemia, MCV reading above upper limit of normal.

[suggestion]

  • H2 antagonists such as cimetidine (stogamet 300mg/tab, tagamet 200mg/2ml/amp available in stock), famotidine (ulstop 20mg/tab, ulcertin 20mg/2ml/amp available), ranitidine (not available in hospital), nizatidine (not available) could be considered to shift PPI off.
  • please monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used.
  • symptoms of domperidone overdosage may include agitation, altered consciousness, convulsions, disorientation, somnolence and extrapyramidal reactions. there is no specific antidote to domperidone, but in the event of overdose, standard symptomatic treatment should be given.
  • some vit B12, folic acid might help to increase HGB.

thanks and regards,

700826905

210927

{dedifferentiated liposarcoma}

[tube feeding]

  • most oral drugs in active medication are patient-carried for her underlying diseses, all the oral drugs can be administered via NG tube.

[objective]

  • 2021-04-22 patho - peritoneum biopsy
    • pathologic diagnosis: compatible with dedifferentiated liposarcoma
    • composed of fascicles of markedly pleomorphic spindle tumor cells embedded in myxoid stroma. subtle lipogenic tumor cells are found. foci of tumor necrosis are present.
    • IHC: CK(-), S100(focal +), CD34(-), smooth muscle actin(-), MDM2 (+), and CDK4(+).

[assessment]

  • palbociclib might be considered for the treatment of unresectable dedifferentiated liposarcoma
    • palbociclib, an inhibitor of cyclin-dependent kinases (CDKs) 4 and 6, induced objective tumor response and a favorable PFS of 56% to 66% in patients with CDK-4-amplified, well-differentiated or dedifferentiated liposarcoma in a phase II study.
    • reference: https://pubmed.ncbi.nlm.nih.gov/23569312/
  • pembrolizumab demostrated clinical activity in resectable dedifferentiated liposarcoma with a 20% overall response rate in a phase II study.

700054780

210920

==========

2021-09-20

[mesna compatibility for common solutions]

reply for the consultation from the ward, mesna is compatible with: - D5W (Dextrose 5% in water) - D5NS (Dextrose 5% in sodium chloride 0.9%) - D5W - 1/2 NS (Dextrose 5% in sodium chloride 0.45%) - NS (Normal saline (Sodium chloride 0.9%)) - Lactated Ringer’s Injection

2021-09-15

[post IPP meeting following up]

busulfan inventory

  • the schedule and regimen for PBSCT for the patient was disclosed in the meeting (with his spouse) held on 2021-09-15 10:30 in the ward.
  • the estimated total amount of busulfan used in the time table is 12 vials.
    • based on busulfan 60mg/10mL/vial, dose 3.2mg/kg, body weight 64.8kg
    • 4 vials per day for 3 days (2021-09-16, 2021-09-17, 2021-09-18)
    • staff to dispense regimen during weekend are arranged.
    • stock in medicine storeroom has been confirmed enough in quantity.

preparation and administration precautions

  • busulfan:
    • do not use polycarbonate syringes or polycarbonate filter needles with the drug.
  • etoposide:
    • precipitation may be exacerbated at concentrations of 0.4 mg/mL or above.
    • etoposide 400mg/m2 x body surface area 1.79m2 -> amount 716mg.
    • total solution containing 716mg etoposide should be no less than 1790mL.
  • mesna administration rate
    • where ifosfamide or cyclophosphamide is used (like this patient) as an iv bolus:
      • mesna is given by intravenous injection over 15-30 minutes at 20% of the simultaneously administered oxazaphosphorine on a weight for weight basis (w/w). the same dose of mesna is repeated after 4 and 8 hours (as listed in the regimen schedule).
    • taking a conservative approach as conclusion, 30 minutes should be safe for adult.

underlying diseases

  • underlying diseases are managed with corresponding medicine without issues.
    • HTN and CAD s/p stent splacement
      • concor (bisoprolol) 2.5mg PO QD
      • norvasc (amlodipine) 2.5mg PO QD
      • tulip (atorvastatin) 10mg PO QOD
    • HBV infected
      • baraclude (entecavir) 0.5mg PO QDAC
    • SLE
      • plaquenil (hydroxychloroquine) 200mg PO QOD

medical compliance

  • the patient showed somewhat self-assertive in the meeting, pleading with tactful words might be needed to prevent potential undesired events.

700142452

210915

{hypoalbuminemia and proteinuria caused by UTI induced nephrotic syndrome?}

[tube feeding]

  • all the oral drugs in active medication can be administered via NG tube.

[objective]

  • serum Ca 2.03mmol/L 2021-09-15
  • Creatine kinase-MB 25.7ng/mL 2021-09-14
  • creatinine 1.67mg/dL 2021-09-14
  • albumin 2.8g/dL 2021-09-14
  • CRP 4.87mg/dL 2021-09-14
  • urine data reported on 2021-09-14
    • PRO 2+
    • OB 2+
    • bacteria 3+

[assessment]

  • elevated CKMB reading could mean possible heart muscle damage. (NT-proBNP 7946pg/mL 2020-02-09)
  • UTI is treated with Sintrix (Ceftriaxone Na) 1000mg IVD QD since 2021-09-15 for 7 days for now.
  • in patients with hypoalbuminemia, total serum calcium concentration will change in parallel to the albumin concentration and may not accurately reflect the physiologically important ionized (or free) calcium concentration.

[suggestion]

  • heart condition might be followed up if no other considerations.
  • first priority might be to mitigate UTI, please keep current medication and monitoring the effects routinely as usual.
  • urine culture might be of help to choose more adequate antimicrobial in the coming days.

701331484

210914

[tube feeding]

  • all the oral drugs in active medication can be administered with NG tube.

[iron supplement]

700842358

210913

[drug interaction]

  • total 22 items in active medication (indlucing 3 in-hospital prescribed and 19 patient-carried drugs) have been reviewed without combinations to be avoided.

[objective]

  • CKD stage 3 management at Shuang Ho Hospital
  • patient-carried drug Furide (furosemide) 40mg QD listed in active medication.
  • lab data reported on 2021-09-13 showed readings above normal limits
    • creatinine 4.83mg/dL
    • eGFR 12.58
    • BUN 78mg/dL
    • Bil T 15.42mg/dL
    • Bil D 8.89mg/dL
    • Alkaline phosphatase 243IU/L
  • serum electrolytes Na, K reported on 2021-09-13 showed normal.
  • relatively low blood pressure recorded on 2021-09-11, -09-12

[assessment]

  • this patient’s liver and kidney functions are somewhat impaired.
  • furosemide
    • for a patient with eGFR <= 30 mL/minute/1.73m2, higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. however, single doses >160 to 200 mg are unlikely to result in additional diuretic effect.
    • diminished natriuretic effect with increased sensitivity to hypokalemia and volume depletion in cirrhosis.
  • diuretics
    • dosing is empiric and frequently determined by the elimination of edema for CKD stage 4 to 5.
    • spironolactone leads to natriuretic response in patients with cirrhosis and ascites or heart failure, particularly used with a loop or a thiazide-type diuretic or both.

[suggestion]

  • please monitor furosemide effect to see if dose increasing or considering spironolactone is needed.

700640254

210907

{ovary cancer s/p debulking surgery}

[history]

  • laparoscopic myomectomy 10 years ago.

[initial presentation]

  • abdominal fullness with palpable mass over right side, poor appetite, easily fullness and nausea sensation when eat a lot, less urine output with voiding hesitation, back soreness and excertional dyspnea since 2021-06.
  • constipation since 2021-07.

[definite diagnosis, disease extent]

  • 2021-07-27 abdominal ultrasound
    • cystic lesion, suspected cystic tumor, lower abdomen
  • 2021-07-28 CT - whole abdomen, pelvis
    • findings
      • a lobulated cystic mass with enhancing mural nodules and few septa in the lower abodmen and pelvis, measuring 20.6 x 12.8 x 26 cm (width x depth x cranial-caudal length). cystic adenocarcinoma of the right ovary is highly suspected.
      • soft tissue nodules and fatty stranding in the omentum of right middle abdomen that may be carcinomatosis. correlate with peritoneoscopy.
      • poor enhancing lesions in the uterus that are compatible with myomas. ill-defined enhancing lesions in the uterine myometrium that are compatible with adenomyosis.
    • image stage
      • T1aN0M0, stage IA
  • 2021-08-16 patho - ovary tumor
    • histologic type: clear cell carcinoma
    • histologic grade: high grade
    • regional lymph nodes: left iliac: 0/1; left obturator: 0/3; right iliac: 0/3; right obturator: 0/6; left paraaortic: 0/1; right para-aortic: 0/1.
    • leiomyomas and endometriosis are seen in myometrium. endometrioma is found in left ovary.
    • aggregation of histiocytes is present in the omentum.
    • IHC stains: PAX8(+), Napsin A(+), WT-1(-), PR(-), and p53(-).

[treatment]

  • 2021-08-16 debulking surgery (ATH + BSO + cytoreduction surgery + omentectomy + LN dissection)

[assessment]

  • clear cell carcinoma of the ovary is a relatively less common ovarian cancer, since the patient is just in her early fifties, her liver and kidney functions showed no abnormality (lab data reported on 2021-08-13), IV platinum-based therapy might be applicable.
    • paclitaxel + carboplatin every 3 weeks for 3 to 6 cycles (hearing test done 2021-09-07 morning)

701205775

210907

{unresectable liver tumor}

[initial presentation]

  • 2021-08-26 coffee ground vomiting, gastrointestinal hemorrhage, hypovolemic shock.

[definite diagnosis, disease extent]

  • 2021-08-27 abdominal ultrasound
    • liver tumors, both lobe
    • parenchymal liver disease
    • cholecystopathy
    • minimal ascites
  • 2021-08-27 CT - whole abdomen, pelvis
    • findings:
      • lobulated patchy geographic poor enhancing cystic-like lesions in right lobe and S4 of the liver, the largest one measuring 14.3 cm in the largest dimension, with patent flow of both lobe portal vein and hepatic vein.
      • several enlarged nodes in the hepatoduodenal ligament are noted and the largest one measuring 2.5 cm that may be metastatic nodes?
      • liver infarction is highly suspected?
      • the differential diagnosis include angiosarcoma, poorly-differentiated HCCs, and metastases.
      • the liver shows irregular contour that may be cirrhosis. enlarged of the spleen (long axis: 12 cm) and minimal ascites in right subphrenic and right perihepatic space that may be portal hypertension.
    • imaging stage:
      • T3N1M0, stage IVA.
  • 2021-08-30 patho - liver biopsy needle/wedge, sono-guided aspiration
    • hepatocellular carcinoma, composed of nests of well differentiated neoplastic hepatocytes, arranged in pseudoglandular and trabecular patterns. extensive coagulative necrosis and hemorrhage are present.
  • 2021-08-30 MRI - liver, spleen
    • bil. liver tumors, angiosarcoma is first considered.

[underlying disease]

  • T2DM, GERD, HTN, hyperlipidemia

[assessment]

  • liver tumor
    • tumor too large to be resectable (low anticipated liver reserve and remnant). this patient is in her early sixties with multiple comorbidities (and probable portal hypertenstion), being a candidate for transplant might be an option but not a highly realistic one.
    • limiting tumor growth or downsizing it to mitigate possible encephalopathy, ascites, hypoalbuminemia, prolonged prothrombin time, hyperbilirubinemia, would be on a general right track in a short-term to medium-term time scale.
    • bevacizumab might not be applicable at the present time for its possible cardiovascular (heart failure), GI (perforation), HTN, hemorrhage adverse reactions.
    • patient-carried stivarga (regorafenib 40mg PO QD) has been listed in active medication since 2021-09-01 during this hospitalization.
  • current symptoms and most of underlying diseases are managed under following drugs without issues:
    • encephalopathy
      • lactul (lactulose) 13.32g PO QD
    • prolonged prothrombin time
      • katimin (phytomenadione) 10mg IVD QD
    • cachexia
      • megest (megestrol) 160mg PO TID
    • edema, ascite
      • plasbumin (human albumin) 50ml IVD BID
      • furosemide 20mg IVD BID
      • spironolactone 25mg PO BID
    • GERD
      • takepron (lansoprazole) 30mg PO QDAC
    • HTN
      • concor (bisoprolol) 1.25mg PO BID
    • T2DM
      • actrapid hm insulin 4unit SC BIDAC
      • relinide (repaglinide) 1mg PO TIDAC15
      • trajenta (linagliptin) 5mg PO QDAC
  • pravafen (pravastatin 40mg, fenofibrate 160mg) QD for hyperlipidemia (lab data on 2021-08-05 remained high readings) listed in PharmaCloud could be considered to add to active medication as a patient-carried item.

700965860

210906

{colon cancer with suspected liver mets and peritoneal seeding}

[initial presentation]

  • 2020-11 underwent a health examination arranged by the company and found multiple liver nodules (2.7 cm).
  • 2021-05 began to suffer from abdominal cramps after eating (below umbilicus) and the symptom can be relieved after defecation.
    • no radiation pain, abdominal distension, burning sensation, nausea, vomiting, diarrhea, constipation, appetite change.
  • 2021-08 LMD abdomenal echo found multiple liver tumors.

[definite diagnosis, disease extent]

  • 2021-08-18 abdominal ultrasound
    • liver tumors, multiple, suspect metastasis
    • several mixed echoic tumors with peripheral low echogenicity, and the largest one 8 cm x 3.9 cm was at S4/8
  • 2021-08-19 CT, ABD - liver, spleen, biliary duct, pancreas
    • multiple liver tumors suspected metastases.
    • wall thickening of cecum and S-colon.
    • a soft tissue nodule (1.3cm) in pelvic cavity suspected tumor seeding.
    • some LNs at paraaortic region suspected metastases.
  • 2021-08-20 coloscopy
    • suspect colon cancer with impending obstruction, sigmoid colon, 30cm above AV, s/p biopsy
    • a large ulcerative tumor involving the whole circumference with lumen narrowing and the scope can not pass through it, s/p biopsy
  • 2021-08-23 patho - colon biopsy
    • adenocarcinoma - pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR(+), PMS2(+), MSH6(+), MSH2(+), MLH1(+).

[assessment]

  • staging workup is ongoing.
    • liver mets and peritoneal seeding are suspected, should be stage IVC if both confirmed positive.
  • diverting ostomy or bypass or stenting might be indicated for imminent obstruction at colon lesion.
  • liver and kidney functions showed no abnormality (lab data on 2021-09-06, 2021-08-16); neither HBV nor HCV was active; systemic therapy would be indicated for this chemo-naive patient.
    • FOLFOX or CAPEOX could be an option, bevacizumab could also be added.
    • pembrolizumab, nivolumab might not be indicated for pMMR (PMS2(+), MSH6(+), MSH2(+), MLH1(+)).
  • KRAS/NRAS/BRAF lab data not found in chart yet.

700261411

210901

{hypophosphatemia, hypokalemia}

[objective]

  • lab data reported on 2021-09-01
    • K(Potassium) 3.0mmol/L, normal 3.5-5.1
    • P(Phosphous) 1.7mg/dL, normal 2.5-5.0

[assessment]

  • available drug
    • potassium phosphate injection 20mL/amp which contains K 88mEq and P 60mM.
  • dosing
    • for patients with mild to moderate hypokalemia (serum potassium 3.0 to 3.4 mEq/L) who do not have ongoing urinary potassium losses, initial administration of 20 to 80 mEq/day is recommended.
    • serum phosphate level 1.5 to 2.2 mg/dL, initial 0.16 to 0.32 mmol/kg (12.8mmol to 25.6mmol for this 80kg patient) over 4 to 6 hours.
  • stability
    • must dilute in NS or D5W to a total volume of 100mL or 250mL
    • for IV infusion only into a central or peripheral vein
    • do not infuse with calcium-containing intravenous fluids

[suggestion]

  • half to one ampoule of 20mL potassium phosphate in no less than 100mL NS or 250mL D5W infusion 4 to 6 hours is recommended.
  • please monitor serum K, P and EKG routinely to check if the intervention gets the readings back to normal.

700990402

210831

{UTI, hypoalbuminemia}

[objective]

  • 2018-04-03 robotic assisted laparoscopic radical cystectomy + pelvic lymph nodedissection + ileal pouch (ShuangHo hospital)
    • cystectomy and ileal conduit for bladder cancer s/p adjuvant radiotherapy, bilateral PCN insertion, and T-colostomy.
  • 2020-05 right femoral neck fracture s/p bipolar hemiarthroplasty (ShuangHo hospital)
  • 2021-05-24 CT - abnominal
    • a 9cm pelvic mass, suspected to be recurrent tumor.
  • 2021 early Jane bilateral PCN placing and colostomy done for obstructive ileus, followed with adjuvant radiotherapy in Cardinal Tien hospital.
  • 2021-06-25 Gyn ultrasound: uterine mass of 5x5cm at the posterior wall of myometrium without clear margin. D&C and ECC showed inflammation and scanty gland cells with squamous metaplasia.
  • 2021-07-13 LAVH, BSO, excision. adhesiolysis for severe adhesion of small intestine.
  • 2021-07-21 chest AP
    • bilateral lung tumors, suspected lung metastasis.
  • 2021-08-04 CT - brain
    • a right frontal lobe. suspected abscess or tumor.
  • 2021-08-04 MRI - brain
    • right frontal tumor (19 mm) with mass effect. metastasis is first considered. D/D: abscess.
    • a suspected aneurysm (2.6 mm x 2.7 mm) near right M1 bifurcation.
  • 2021-08-30 urine lab data
    • sediment RBC 6-9
    • sediment WBC 10-19
    • leucocyte ester 2+
    • OB 1+
  • 2021-08-22, 23 urine culture - catheterized and patient urinated midstream
    • Klebsiella pneumoniae, Escherichia coli
  • bilirubin direct 0.32mg/dL (2021-08-23)
  • albumin
    • 2021-08-23 2.7g/dL
    • 2021-07-26 3.1g/dL
    • 2021-07-22 3.0g/dL
    • 2021-07-19 2.8g/dL
    • 2021-07-01 2.9g/dL
    • 2021-06-24 2.8g/dL
  • prealbumin
    • 2021-07-26 10.04mg/dL
    • 2021-07-14 10.64mg/dL

[assessment, suggestion]

  • UTI still ongoing (8/30 urine lab data), 1 week tapimycin administrated until 9/1 morning, imipenem might be an alternative successor for both cultured Klebsiella pneumoniae and Escherichia coli are imipenem-sensitive (MIC<=0.25, low creatinine reading) if no other considerations.
  • S-GPT/ALT and S-GOT/AST (8/23) showed no abnormality, however, bilirubin flucturated above normal range for at least 3 months. both albumin and prealbumin remain low, if no evidence supports liver-dysfunction-caused hypoalbuminemia for now, to improve patient’s nutritional status could be tried. HBV and HCV might also be tested (no in-hospital records seen yet).
  • underlying diseases or symptoms are managed with drugs in active prescription, no issue found.
    • type 2 DM
      • metformin 500mg PO BID
      • linagliptin 5mg PO QD
    • hypertension
      • amlodipine 5mg PO QD
    • parkinson’s disease
      • bendopar (levodopa 100mg, benserazide 25mg) PO BID+HS
      • amentadine 100mg PO BID
    • flatulence
      • dimethylpolysiloxane 40mg PO BID

700031883

210830

{esophageal scc with lung and stomach mets}

[definite diagnosis, disease extent]

  • 2018-04-26 surgical pathology level IV
    • esophagus, 26 cm below incisor, biopsy - moderately differentiated squamous cell carcinoma
    • IHC stains P40(+), p63(+), CK(+), CDX-2(-).
  • 2018-05-07 CT - mediastinum
    • imp: M/3 esophageal tumor T1N0Mx.
  • 2019-08-20 CT - mediastinum
    • LUL cancer T1aN0MO stage IA1.
  • 2019-11-21 CT - mediastinum
    • s/p esophagectomy with gastric tube reconstruction.
    • left upper lobe nodule.
  • 2021-06-03 PET whole body scan
    • glucose hypermetabolic lesion in the left paratracheal area, compatible with recurrent malignancy.
    • mild glucose hypermetabolism in a right submandibular lymph node, a right neck level III lymph node, bilateral pulmonry hilar regions and in some focal areas in bilateral buttocks.
  • 2021-06-25 cell block cytology & needle aspiration cytology
    • stypical hyperchromatic pleomorphic tumor cells with focal keratinization.
    • metastatic squamous cell carcinoma is favored.
  • 2021-06-25 patho - stomach biopsy
    • nests of hyperchromatic tumor cells infiltration in fibrous tissue. keratinization is focally present.
    • IHC stains CK5/6(+), p40(+), TTF-1(-), Napsin A(-), CD56(-), and Synaptophyin(-).
    • the results are in favor of metastatic squamous cell carcinoma.

[treatment]

  • 2018-06-04 op for scc of middle third esophagus
    • the esophagus was dissected, and retrosternal route was created and connected to abdomen.
    • the gastric tube was draw up to the cervical incision via retrosternal route.
  • 2019-11-29 VATS left upper lobe wedge resection, lobectomy with RLND.
  • 2021-07 up to now: CCRT
    • chemo part - PF 2021-07-29, -08-27
      • 75mg/m2 day 1
      • 1000mg/m2 day 1~4
    • radio part - 3440Gy/19fx 2021-07-01 ~ -07-27

[assessment]

  • visiting the patient at around 16:40 on 2021-08-30. he said the treatments were generally well-tolerated and he did not experience any side effects need intervention during this hospitalization.
  • overall good, no issue on medication.

700295989

210826

{duplicated NSAIDs}

[objective]

  • NSAIDs listed in active medication as following:
    • Laston (ketorolac) 30mg IM PRNQ6H
    • Deflam-K (diclofenac) 25mg PO QID
    • Deflam-K (diclofenac) 25mg PO QID - patient carried

[assessment]

  • diclofenac could be administered up to 200mg per day.
  • diclofenac exceeding 100 mg per day might increase risk of vascular events.
  • ketorolac is also classified as NSAID.

[suggestion]

  • either in-hospital prescribed or patient carried diclofenac could be discontinued if no other clinical considerations.

701255029

210826

{potential drug interaction}

[objective]

  • the following drugs are listed in active medication:
    • morphine, tramadol
    • cyproheptadine, quetiapine
    • atorvastatin
    • daptomycin

[assessment]

  • atorvastatin is an HMG-CoA reductase inhibitors which might enhance the adverse effect of daptomycin, the risk of skeletal muscle toxicity might be increased.
  • cyproheptadine and quetiapine coadministered with opioid agonists i.e. morphine and tramadol might enhance the CNS depressant effect.

[suggestion]

  • please monitor any sign of the potential adverse effects mentioned above.

700522826

210825

{breast cancer}

[initial presentation]

  • left breast lump found since 2021 May/June

[definite diagnose, disease extent]

  • 2021-07-23 SONO breast, Mammography
    • hyperdense tumors in left breast, 4.9cm (subareolar region) and 1.7cm (deep central), suspected malignancy, suggest biopsy.
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
  • 2021-07-23 Patho - breast biopsy
    • breast, 4/5’ and 12’ region, left, invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis.
    • the tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.
    • IHC stain ER(-), PR(-), Her2/neu(3+), p53(+), Ki-67 index 20%.
  • 2021-08-06 Patho - lymphnode biopsy
    • benigh lymph node tissue, IHC stain CK(-)
  • 2021-08-09 Tc-99m MDP bone scan
    • no strong evidence of bone metastasis.
  • 2021-08-09 CT - abdomen, pelvis
    • left breast tumor (2.1cm, 4.9cm) with skin invasion suspected cancer.

[treatment]

  • chemo regimen AC (doxorubicin/cyclophosphamide) since 2021-08-25.

[assessment]

  • cT3N0 her2-positive, tumor > 1cm, chemo with trastuzumab (or pertuzumab) could be indicated.
    • however, there are limited data to confirm chemo regimen for those > 70 y of age.
  • CBC WNL, liver and kidney function well, based on most recent lab data.
  • no drug allergy record found in database.
  • MSI/MMR, PD-L1, BRCA1/2, PIK3CA tests could also be considered.

700371268

210824

{tube feeding}

meitifen (diclofenac Na 75mg) PO QD which is controlled-release design might be changed to defram-k (diclofenac K 25mg) PO TID

700770648

210824

{preparation and precaution - mephalan, post-IPP meeting following up}

patient family meeting and IPP meeting was held at 10:00 on 2021-08-24.

  • the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.

  • melphalan dosing as a conditioning agent, 140mg/m2 or 200mg/m2 are more commonly seen. source:

  • the estimated total amount of melphalan used prior to the scheduled transplantation would be 8 vials.

    • based on melphalan 50mg/vial, dose 100mg/m2 (according to the time table), body surface area 1.64m2.
    • 4 vials per day for 2 days (2021-08-29, 2021-08-30).
    • 8 vials in stock has been confirmed by the medicine storeroom.
  • preparation and administration precautions of mephalan:

    • expiration time is 60 minutes after preparation (the duration including infusion time) according to package insert.
      • staff in chemo preparation room will inform the ward when the melphalan preparation is done.
    • based on lab data reported on 2021-07-09 and 2021-07-30, liver and kidney have no abnormality, no dose adjustment is needed.
  • damage of the oral mucosa together with profound myelo- and immunosuppression after transplantation may lead to local and systemic infections.

    • other side effects in the early period may include bleeding due to thrombocytopenia as well as pain, nutrition, and articulation impairment caused by mucositis.
    • in the first year after transplantation, oral cavity is affected by delayed complications like hyposalivation, taste disorders, and dentin hypersensitivity, which often importantly decrease the patients’ quality of life.
    • oral and maxillofacial surgery department has been consulted for this.
    • if oral mucosa damage happens, some triamcinolone acetonide oral ointment (nincort or oralog, the former is available now) for local treatment might be of help.

701118237

210820

{sepsis and pancytopenia with underlying DLBCL}

[subjective]

  • this 64 y/o female patient sent by her family to our ER on 2021-08-11 for her dizziness and hypotension after having chemotherapy.
  • underlying history of (neck) diffuse large B cell lymphoma

[objective]

  • 2021-08-11 ER Imp: sepsis, unspecified organism
  • DLBCL
    • 2019-09-24 CT, neck-hypopharynx:
      • diffuse enlarged lymph nodes on both sides of neck, more prominent on right side.
      • D/D: lymphoproliferative disease, metastases.
    • 2019-09-27 surgical pathology level IV:
      • pathologic diagnosis
        • Lymph node, level IV, right neck, dissection— B- cell lymphoma
        • Lymph node, level III, right neck, dissection— B- cell lymphoma
      • Histology type:
        • B-cell lymphoma (favor diffuse large B-cell lymphoma)
      • Immunohistochemical stain profiles:
        • CD20(+), Bcl-2(+), CD3(focal positive at the background T-cells), Bcl-6(+), Sox11(-), cyclin-D(-), CD10(-), Ki-67 index:70%, CD5 (focal+), c-myc(-), CD23(-).
    • 2020-11 bone marrow transplant, followed up at NTUH
    • 2021-05 recurrence, neck mass noted
    • 2021-07 PET showed progressing
    • 2021-08-06 chemotherapy endoxan (cyclophosphamide) prescirbed (according to PharmaCloud), pre-chemotherapy WBC 1600
  • Lab data
    • RBC 2021-08-20 3.45*10^6/uL
    • HGB 2021-08-20 10.1g/dL
    • PLT 2021-08-20 52*10^3/uL
    • WBC
      • 2021-08-20 3.65*10^3/uL
      • 2021-08-18 1.69
      • 2021-08-17 1.02
      • 2021-08-16 0.43
      • 2021-08-14 0.10
      • 2021-08-13 0.08
      • 2021-08-11 0.10
    • CRP
      • 2021-08-16 15mg/dL
      • 2021-08-11 12
    • urine culture on 2021-08-17: after 48 hours, <1000 CFU/ml
    • blood culture on 2021-08-12: no growth for 5 days aerobically & anaerobically
  • medication
    • granocyte (lenograstim) 250mcg SC QD since 2021-08-12
    • cefim (cefepime) 2000mg IVD Q12H 2021-08-12 to 2021-08-18
    • eraxis (anidulafungin) 100mg IVD QD
    • targocid (teicoplanin) 600mg IVD Q12H~QD 2021-08-12 to 2021-08-16

[assessment]

  • sepsis
    • urine culture and blood culture found no obvious infection
    • body temp no higher than 36.8 since last week
    • CRP still showed elevated.
    • after days of ABX administration, the infection should has been mitigated.
  • pancytopenia
    • WBC has been boosted by lenograstim
    • RBC and PLT still below than LLN, but moved out of critical range.
    • the condition has been improved.
  • DLBCL
    • alkylating agent been paused (not listed in active medication) because of pancytopenia.

[suggestion]

  • ABX might be deescalated when CRP goes down and no other infectious sign shows up.
  • DLBCL treatment should be restarted as soon as possible when the patient gets in stable condition.
    • no chemo or target drugs other than cyclophosphamide found in PharmaCloud, based on the limited info, ISRT after RCHOP might be a treatment option.
    • uric acid, beta-2 microglobulin could also be followed up when having DLBCL treatment.
  • HBV, HCV lab data not found in in-hospital database, could be ordered.

701034857

210816

{liver cancer with bone mets}

[initial presentation]

  • 2017~ abdominal fullness

[definite diagnosis, disease extent, effect & side effect]

  • 2017-09-20 Echo for liver, gall bladder, pancreas, spleen
    • parenchymal liver disease; postcholecystectomy; liver cyst; hepatic tumors, three suspected HCC
  • 2018-04-03 CT, ABD - liver, spleen, biliary duct
    • HCCs s/p operation and TACE without viable tumor.
  • 2018-07-25 Echo for liver, gall bladder, pancreas, spleen
    • parenchymal liver disease; postcholecystectomy; liver cyst; probable hepatic tumor; renal stone, left
  • 2018-12-26 Echo for liver, gall bladder, pancreas, spleen
    • liver cirrhosis; postcholecystectomy; hepatic tumor, nature?
  • 2019-03-03 CT, ABD - liver, spleen, biliary duct
    • HCC s/p TACE with recurrent HCC at S3 and S7.
  • 2019-05-08 Echo for liver, gall bladder, pancreas, spleen
    • parenchymal liver disease; hepatic tumors, two c/w HCC; increased risk of RFA due to near diaphargm
  • 2019-06-29 CT, ABD - liver, spleen, biliary duct
    • HCC s/p op. and TACE with viable tumor at S7.; liver cirrhosis.
  • 2019-09-23 MRI, liver, spleen
    • a recurrent HCC (2.0cm) in S7 of liver.
  • 2020-02-03 CT, ABD - liver, spleen, biliary duct
    • HCCs s/p operation and TACE. a recurrent HCC (2.9cm) in S7 of liver.
  • 2020-05-13 Abdominal Ultrasonography
    • liver cirrhosis; hepatic tumors, two probable hcc
  • 2020-12-30 Abdominal Ultrasonography
    • liver cirrhosis; hepatic tumors, three c/w hcc
  • 2021-05-24 CT, ABD - liver, spleen, biliary duct
    • HCCs s/p operation and TACE. recurrent HCCs (up to 4.3cm) in S7-8 of liver. some lucent lesions in left pelvic bone probable metastases.
  • 2021-05-26 Abdominal Ultrasonography
    • liver cirrhosis; hepatic tumors, five c/w HCC (two s/p TACE with viable tumors, three recurrent).

[treatment]

  • HCC op and TACE done at other hospital in late 2017.
  • entecavir been used years ago, restarted from 2021-07-03 (self-paid).
  • nexavar (sorafenib) 200mg BIDAC tappered to QDAC because of poor appetite, dizziness, malaise.
  • palliative RT to the Lt shoulder to deliver at least 30 Gy/ 10 fx started in the middle third of 2021-08.

[assessment]

  • medication
    • no issues with the following indications
      • HCC
        • nexavar (sorafenib 200mg) PO QDAC (Child-Pugh Class A)
      • HBV, cirrhosis
        • baraclude (entecavir 0.5mg) PO QDAC
        • baogan (silymarin 150mg) PO BID
    • potential interaction
      • the antitumor activity of sorafenib might be potentially reduced by neomycin for the later may decrease the serum concentration of the former.
  • radiotherapy
    • palliative RT is appropriate for symptom control and/or prevention of complications from metastatic lesions, such as bone (like this patient) or brain.
  • patient wants to take herbal medicine.
    • not being followed up with chinese medicine department since late 2017
    • no herbal medicine items disclosed in PharmaCloud.
  • dMMR/MSI-H, NTRK, BRCA1/2 gene tests not found in the charts

[suggestion]

  • introduce the patient to visit our chinese medicine OPD to get ‘scientfic chinese medicine’ rather than using unknnow herbal medicine.
  • shorten the use time of meomycin to avoid potential drug interaction with sorafenib.
  • dMMR/MSI-H, NTRK, BRCA1/2 gene tests might be ordered if needed.
  • the patient seemed being hesitating to have curative care for a not short while and hopping from and to WanFang hospital for medical demand, having him to meet with social-work staff might be of help to get his considerations behind.

701326125

210816

{some preparation before tube feeding}

active medication is reviewed, all the oral drugs can be administered via NG tube.

acetin (acetylcysteine) and nexium (esomeprazole) should be dissolved in adequate drinking water prior to tube feeding.

701326360

210816

{switch drug for tube feeding}

active medication has been reviewed, all the oral drugs can be administered via NG tube.

Harnalidge (tamsulosin) 0.4mg PO QDAC replaced by Urief (silodosin) 8mg PO QD is recommended.

700321047

210812

{statin dose intensity and equivalency}

All the oral drugs in active medication have been reviewed and can be administered via NG tube.

Pravafen has not been found in active medication yet.

Pravafen should not be grinded or half-peeled. It contains fenofibrate 160mg and pravastatin 40mg, there is Lipanthyl Supra (fenofibrate 160mg) available in hospital, however pravastatin 40mg is out of stock for now.

Fluvastatin 80mg, lovastatin 80mg, simvastatin 20mg, pitavastatin 2mg, atorvastatin 10mg, rosuvastatin 5mg are alternatives for pravastatin 40mg. reference: http://www.mqic.org/pdf/UMHS_Statin_Dose_Intensity_and_Equivalency_Chart.pdf

701320982

210812

{lung cancer with brain mets}

[initial presentation]

  • 2021-07-12 being diagnosed as hypnic headache at LMD.
  • 2021-07-26 intermittent occipital headache accompanied with Rt limbs weakness for 2 weeks, exacerbated since 2021-07-24.

[definite diagnose, disease extent]

  • 2021-07-26 CT, brain:
    • masses in right cerebrum; DDx: metastasis, meningiomas.
    • midline shift (11mm) and impending uncal herniation.
  • 2021-07-26 MRI, brain:
    • bifrontal and right medial temporal tumors, favor metastases, with brain herniation.
  • 2021-07-27 CT, lung/mediastinum/pleura:
    • LUL lung cancer, T4N3M1c, stage IVB.
  • 2021-07-28 whole body PET scan:
    • glucose hypermetabolism in the right cerebral cortex, probably the primary or secondary (priority) brain malignancy.
    • glucose hypermetabolism in the left upper lung and left lower lung pleura, probably lung cancer with lung to lung metastases.
    • glucose hypermetabolism in bilateral mediastinal lymph nodes and bilateral SCF lymph nodes, probably lung cancer with regional lymph nodes metastases.
    • left upper lung cancer (if proved), cT4N3M1c, stage IVB.
  • 2021-07-30 patho, lung transbronchial biopsy:
    • adenocarcinoma, moderately to poorly differentiated. solid nests and glandular cells infiltrating in a fibrotic stroma.
    • ICH stains: TTF-1(+), Napsin A(+), p40(-), CD56(-) are supportive for lung cancer diagnosis.
  • 2021-08-04 PD-L1:
    • tumor cell (TC) staining assessment: <1%
    • tumor-infiltrating immune cell (IC) staining assessment: <1%

[treatment]

  • Radiotherapy
    • palliative RT for brain metastases is indicated.
    • delivering 18 Gy/ 6 fx to the whole brain and then boost the bi-frontal and Rt medial temporal tumors to 36 Gy/ 12 fx.

[assessment, suggestion]

  • active medication without issues
    • brain mets:
      • Mannitol 20% 100mL IVD Q8H
      • Keppra (levetiracetam) 500mg PO BID
    • insomnia:
      • Anxiedin (lorazapam) 0.5mg PO PRNHS
    • constipation:
      • MgO 500mg PO TID
  • PD-L1 <1% is known. EGFR, KRAS, ALK, POS1, BRAF V600E, NTRK, METex14, RET might be tested
  • if CCRT is applicable, the chemo option could be:
    • carboplatin + pemetrexed
    • cisplatin + pemetrexed
    • paclitaxel + carboplatin
    • etooside + cisplatin

701253142

210811

{cecal cancer}

[initial presentation, definite diagnosis, disease extent]

  • 2019-12-15 CT at TMUH: cecal or appendiceal malignancy with adjacnet infiltration, few prominent regional lymph nodes and liver metastasis.
    • no blood stool and no stool impaction could be noted prior to the CT exam.

[treatment]

  • 2020-02-10 ~ 2020-11-xx: biweekly high dose 5-fluorouracil and leucovorin (HDFL) at TMUH?
    • outcome: partial response
  • 2020-12-07 ~ up to now : continuing HDFL.
    • plus UFT (tegafur + uracil) from 2020-09 ~ 2020-12.
    • plus Xeloda (capecitabine) from 2021-05 ~ up to now.

[effect & side effect]

  • 2020-11-07 CT, ABD:
    • regression of cecum tumor and liver metastasis.
    • right adrenal tumor, suspect adrenal mestasis, mild progression.
  • 2021-02-22 CT, ABD:
    • stable condition of cecal tumor and liver metastases.
    • wall thickening of urinary bladder, right aspect.
    • mild regression of right adrenal tumor.
  • 2021-04-13 KUB:
    • S/P posterior instrumentation fixation from T10 To L5.
    • S/P laminectomy of L2, L3, and L4; partial laminectomy of L5
    • vacuum phenomenon of L4-5.
    • fecal material store in the colon.
  • 2021-04-15 KUB:
    • S/P posterior longitudinal transpedicular screws and rods fixation.
    • stool retention in the bowel.
  • 2021-05-22 CT, ABD:
    • borderline heart size.
    • s/p posterior fixation of the lumbar spine
    • cecal tumor with liver meta, right adrenal meta(?), statinoary.
  • 2021-07-16 CT, ABD: left hydronephrosis and hydroureter. focal wall thickening of urinary bladder. urinary bladder and left lower ureter tumors should be ruled out.
  • 2021-08-02 kidney ultrasound: right renal cyst.
  • 2021-08-02 bladder sonography: post-void residual volume 297ml
  • CEA
    • 2021-08-10 _9.55ng/mL
    • 2021-07-06 11.17
    • 2021-06-08 10.43
    • 2021-05-11 _5.05
    • 2021-04-13 _5.63
    • 2021-03-17 _4.50
    • 2021-02-03 _5.34
    • 2021-01-06 10.98
    • 2020-12-22 16.63
    • 2020-12-03 32.41
    • 2020-11-05 40.06
    • 2020-09-25 21.92
  • CA199
    • 2021-08-10 _37.74U/mL
    • 2021-07-06 _42.15
    • 2021-06-08 _37.56
    • 2021-05-11 _24.28
    • 2021-04-13 _27.14
    • 2021-03-17 _25.11
    • 2021-02-03 _26.37
    • 2021-01-06 _31.50
    • 2020-12-22 _41.91
    • 2020-12-03 _95.77
    • 2020-11-05 119.26
    • 2020-09-25 119.70

[ongoing problem]

  • BPH
    • medication
      • Avodart (dutasteride) 0.5mg PO QD
      • Betmiga (mirabegron) 50mg PO QD
      • Urief (silodosin) 8mg PO QD
  • HTN
    • medication
      • Diovan (valsartan) 80mg PO QD

[assessment]

  • patient is relatively stable with slow tumor progression.
  • mirabegron is a CYP2D6 inhibitor which might increase the serum concentration of metoclopramide (10mg IVD PRNQ6H).
    • CYP2D6 is an enzyme responsible for metoclopramide metabolism.

700081580

210810

{renal glucosuria?}

[initial presentation]

  • 2021-07-15 left inguinal mass for 3 weeks refer from LMD.
  • 2021-07-16 CT - abdomen, pelvis:
    • a well-defined soft tissue mass measuring 2.6 x 2.3 cm in left inguinal area.
    • differential diagnosis include undescended testis.

[definite diagnosis]

  • 2021-07-28 patho - lymph node regiion resection:
    • labeled as ‘inguinal tumor’, tumor excision - in situ follicular neoplasm.
      • IHC stains: CD3 and CD20: a predominant B cell subpopulation;
      • bcl-2 (+), bcl-6 (+), CD10 (+) of the follicules.
      • CD23 (-), cyclin-D (-).
    • sections show lymph node with proliferative lymphocytes deminstrating pseudofollicles.

[disease extent]

  • 2021-08-10 CT - abdomen, pelvis:
    • only one enhanced lymph node at left inguinal region.
    • the rest of the body part is free of lymphadenopathy.

[objective]

  • 2021-07-27 lab data:
    • urine glucose 4+
    • urine bacteria 1+
    • serum glucose 103mg/dL
  • creatinine WNL:
    • 2021-08-08 0.83mg/dL
    • 2021-07-27 0.74mg/dL
    • 2021-07-15 0.85mg/dL

[assessment]

  • patients with renal glycosuria, glucose is excreted in the urine in the presence of normal or low concentrations of blood glucose.
  • there is a lowered renal threshold to glucose and, in some cases, a reduction in the rate at which the renal tubules are able to reabsorb glucose.
  • in most affected individuals, renal glycosuria is a benign condition, resulting in no apparent symptoms. however, in some cases, glycosuria may be pronounced enough to result in excessive urination (polyuria), excessive thirst (polydipsia), and other associated symptoms.

[suggestion]

  • if any symptomatic sign is observed, appropriate testing should be conducted to rule out diabetes and to regularly monitor those with confirmed renal glycosuria.
  • genetic counseling will be of benefit for affected individuals and their families. other treatment for this condition is symptomatic and supportive.

700223143

210806

{flumarin side effect monitoring}

[objective]

  • flumarin (flomoxef sodium) dosing for adult:
    • susceptible infections IV usual dosage: 1 to 2 g per day in 2 divided doses
    • may increase to 4g per day in 3 to 4 divided doses if needed for severe or refractory infections.
  • flumarin 1g IVD QD is prescribed.
  • estimated creatinine clearance 10ml/min using the Cockcroft-Gault equation is based on:
    • age 28 years old
    • body weight 62.65kg (2021-08-05)
    • creatinine 7.00mg/dL (2021-08-06)
  • according to the drug’s package insert, half-life t1/2:
    • healthy adult: 49.6min
    • patient with 5 < CrCl < 20: 6.95hr

[assessment]

  • half-life for the patient could be 8.4 times long compared to normal renal function adults.
  • prescribed dose is a quarter of upper limit of daily use, not as low as one eighth, might increase the possibility of adverse reactions.

[suggestion]

  • please monitor any signs of adverse reactions possibly caused by flumarin including:
    • dermatologic: skin rash
    • endocrine & metabolic: increased gamma-glutamyl transferase
    • gastrointestinal: diarrhea
    • hematologic and oncologic: anemia, eosinophilia, granulocytopenia
    • hepatic: increased serum alkaline phosphatase, increased serum ALT, increased serum AST

700834580

210806

{cancer workup}

[initial presentation]

  • 2021-06-30 left leg knee and thigh pain for more than one month, progresson
  • 2021-07-14 limping gait, severe pain lower back radiating to left hip and lower leg

[objective]

  • lab data (2021-07-28)
    • CA125 645U/mL
    • CA199 >19610U/mL
    • CEA 613ng/mL
    • CA153 WNL
    • AFP WNL
    • SCC WNL

[definite diagnosis & staging workup]

  • still in workup, could be lung to bone mets, evidences observed including:
    • 2021-07-15 MRI L-spine:
      • tumors in the left iliac bone and right sacrum. origin?
    • 2021-08-04 Tc-99m MDP bone scan:
      • lung cancer with multiple bone metastases in the lower part of the sternum, posterolateral aspect of the left 10th rib, and left iliac bone is highly suspected.
    • 2021-08-05 bronchoscopy:
      • right intermediate bronchus submucosal tumor.
      • RLL orifice submucosal tumor, some protuding to the mucosa layer, with RLL bonchus narrowing.

[treatment]

  • pain
    • morphine 15mg PO Q6H
    • morphine 5mg IVD PRNQ6H
  • constipation
    • through (sennoside) 24mg PO HS
    • bisacodyl 10mg RECT PRNQD
    • MgO 500mg PO Q6H

[ongoing problem]

  • post nasal dripping
    • actein (acetylcysteine) 200mg PO BID
    • sindecon nasal spray 1 puff NA BID
  • hyperlipidemia
    • crestor (rosuvastatin) 10mg PO QD
  • insomnia
    • anxiedin (lorazepam) 0.5mg PO HS

[assessment]

  • main activity is to control (pain) symptoms for now
  • constipation which could be an adverse reaction of morphine has been mitigated with stimulant laxatives.

700039230

210729

{post IPP meeting following up}

  • the schedule and regimen for PBSCT for the patient was disclosed in the meeting held on 2021-07-28 10:30.

  • the estimated total amount of busulfan used in the time table is 15 vials.

    • based on busulfan 60mg/10mL/vial, dose 3.2mg/kg, body weight 75kg
    • 5 vials per day for 3 days (2021-07-28, 2021-07-29, 2021-07-30)
  • staff dispensing regimen during weekend are arranged.

  • preparation and administration precautions:

    • busulfan:
      • do not use polycarbonate syringes or polycarbonate filter needles with the drug.
    • etoposide:
      • precipitation may be exacerbated at concentrations of 0.4 mg/mL or above.
      • etoposide 400mg/m2 x body surface area 1.9m2 -> amount 760mg.
      • total solution containing 760mg etoposide will be no less than 1900mL.

{mesna administration rate}

  • where ifosfamide or cyclophosphamide is used (like this patient) as an iv bolus: mesna is given by intravenous injection over 15-30 minutes at 20% of the simultaneously administered oxazaphosphorine on a weight for weight basis (w/w). the same dose of mesna is repeated after 4 and 8 hours (as listed in the regimen schedule).
  • taking a conservative approach as conclusion, 30 minutes should be safe for adult.

700274711

210729

{colon cancer}

[initial presentation]

  • 2019-08 intermittent low abdominal cramping pain and fullness, LMD FOBT positive.

[definite diagnosis and disease extent]

  • 2019-09-19 patho, hemicolectomy:
    • descending colon, adenocarcinoma, moderately differentiated
    • IHC stains - EGFR(+), PMS2(+), MLH1(+), MSH2(+), MSH6(+).
    • pStage IVA, pT3N0M1a

[treatment]

  • 2019-09-18 laparoscopic left hemicolectomy
  • 2020-01-06 ~ 2020-03-16 FOLFOX x 6 (biweekly for 3 months, adjuvant)
  • 2021-07-09 VATS RUL wedge resection
  • 2021-07-27 ~ up-to-now FOLFIRI

[effect & side effect]

  • 2021-07-09 patho, lung wedge biopsy:
    • adenocarcinoma, IHC stains: CK7(-), CK20(+), CDX2(+), TTF-1(-).
    • the morphology and immunohistochemical stains are consistent with metastatic colonic tumor.

[ongoing problem]

  • colon cancer
    • assessment
      • FOLFIRI is introduced in the end of July 2021 soon thereafter lung mets wedge resection
      • MMR proficient, KRAS/NRAS not detected, BRAF, HER2 lab data not found.
      • updated CEA, CA199 within normal limits.
    • suggestion
      • keep the ongoing new regimen and surveilling every 3 to 6 months.
      • bevacizumab might be indicated.
  • HBV
    • lab
      • 2021-07-23
        • Anti-HBc reactive
        • Anti-HBc-Value 5.56 S/CO
      • 2021-07-22
        • S-GPT/ALT 23 U/L
        • S-GOT/AST 23 U/L
    • medication
      • baraclude (entecavir 0.5mg) PO QDAC
    • assessment
      • in stable condition
  • HTN
    • BP around 130/80 plus or minus 10 the first 2 days this hospitalization.
    • medication
      • norvasc (amlodipine 5mg) PO QD
      • syntrend (carvedilol 25mg) PO QD
    • assessment
      • in stable condition
  • BPH
    • medication
      • avodart (dutasteride 0.5mg) PO HS
    • assessment
      • in stable condition
  • hypertriglyceridemia
    • lab
      • 2021-07-08 494mg/dL
      • 2021-03-31 261mg/dL
      • 2021-01-08 339mg/dL
      • 2020-11-11 322mg/dL
      • 2020-04-13 592mg/dL
    • assessment
      • elevated serum TG for at least 1+ year.
    • suggestion
      • statin could be considered if not contraindicated.

700890235

210727

{coadministration of Decan and Juluca}

[objective]

  • active medication include
    • Decan (dexamethasone) 6mg IVD QD
    • Juluca (dolutegravir 50mg, rilpivirine 25mg) 1 tab PO QNCC
  • lab data on 2021-07-22 showed lower lymphocyte percentage, however other items were within normal range:
    • WBC 9.20*10^3/uL
    • Lymphocyte 14.3%
    • Lymphocyte count 1320/uL
    • CD3+/CD4+ Helper T 31.7%
    • CD3+/CD4+ Helper T C 418/uL
    • CD3+/CD8+ Suppre T 31.8%
    • CD3+/CD8+ Suppre T C 419/uL
    • CD4/CD8 Ratio 1.0
    • T Cells (CD3) 61.9%
    • B Cells (CD19) 9.7%

[assessment]

  • rilpivirine prescribing information lists coadministration with multiple-dose dexamethasone as contraindicated due to a risk of decreased rilpivirine concentrations and loss of virologic response.
  • the presumed primary mechanism of interaction between these agents is dexamethasone induction of CYP3A4 mediated rilpivirine metabolism.

[suggestion]

  • please keep monitoring virologic responses.

700539680

210722

{vaccination for splenectomised patients}

[objective]

  • this patient had splenectomy done on 2021-05-12 (huge spleen, >30cm in length, weight 2000g)

[assessment]

  • splenectomised patients are at risk for severe and overwhelming infections with encapsulated bacteria, bloodborne parasites.
  • measures for preventing these infections include patient and family education, vaccination against encapsulated bacteria.
  • vaccines are available to against bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Bordetella holmesii.
  • these vaccines are all in inactivated, noncellular form, not classified as attenuated, relatively safe for patients receiving chemotherapy.

[suggestion]

  • as a general guide, vaccine dose could be administered when patient is in stable condition and during chemo window period. the dose should be repeated no less than 6 months after chemotherapy.

701282961

210722

{suspected MDS}

[objective]

  • 2021-07-12 patho - bone marrow biopsy:
    • piece(s) of bone marrow with 70-80% cellularity and M:E ratio of approximately 1:4.
    • three cell lineages are present with normal maturation of leukocytes.
    • megakaryocytes are increased in number with nuclear atypia. myelodysplastic syndrome with no excessive blasts cannot be excluded.
    • IHC stains (of the nucleated cells):
      • CD117: <1%
      • CD34: <1%
      • MPO: 10-15%
      • CD61: 10-15%
      • CD71: 70-80%

[assessment]

  • driver mutations are detected in >90 percent of cases of MDS. most commonly mutated genes are DNMT3A, TET2, IDH genes, ASXL1, TP53, RUNX1, SF3B1, U2AF1, SRSF2, ZRSR2.
  • chromosomal abnormalities are presumptive evidence of MDS in patients with otherwise unexplained refractory cytopenia and no morphologic evidence of dysplasia, including:
    • unbalanced chromosomal abnormalities:
      • loss of chromosome 7 or del(7q)
      • del(5q) or t(5q)
      • del 20(q)
      • isochromosome 17q or t(17p)
      • loss of chromosome 13 or del(13q)
      • del(11q)
      • del(12p) or t(12p)
      • del(9q)
      • idic(X)(q13)
    • balanced chromosomal abnormalities:
      • t(11;16)(q23.3;p13.3)
      • t(3;21)(q26.2;q22.1)
      • t(1;3)(p36.3;q21.2)
      • t(2;11)(p21;q23.3)
      • inv(3)(q21q26.2) or t(3;3)(q21.2;q26.2)
      • t(6;9)(p23;q34.1)

[suggestion]

  • no issue with current medication, chromosome tests has just been ordered on 2021-07-22, treatment plan will be more clear after having the outcome.

700825772

210721

{Rectal Cancer with UTI}

[objective]

  • exams
    • 2021-07-20 urine culture: Escherichia coli.
    • 2021-05-18 patho - vaginal biopsy:
      • adenocarcinoma characterized by solid, villous or tubular pattern of tumor cells with necrosis.
      • immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+), PMS2(+) and GATA-3(-) for tumor cells, compatible with recurrent rectal adenocarcinoma.
    • 2021-05-17 CT - ABD:
      • rectal cancer s/p operation. a soft tissue lesion (3.0x4.1cm) at right presacral region. some nodules (up to 1.1cm) in bil. lungs.
    • 2021-01-26 CT - ABD:
      • post-op at the rectum with recurrence in presacral region, involvement of distal ureter and sigmoid colon.
      • progression of right hydronephrosis and hydroureter.
      • left lower lung nodule, suspected lung metastasis.
    • 2020-08-27 whole body PET:
      • in comparison with the previous study on 2019/12/23, a new glucose hypermetabolic lesion in the midline pre-sacral region. malignancy with local recurrence should be watched out.
      • another new glucose hypermetabolic lesion in the upper lobe of left lung. the nature is to be determined (a metastatic lesion? other nature?).
      • no prominent change was noted in the previous lesion in right pre-sacral region.
    • 2020-04-02 CT - lung/mediastinum/pleura
      • left upper lobe and right upper lobe dense nodules, old insult is more favored.
  • tests
    • Fecal Occult Blood 4+ (2021-07-17)
    • CEA 46ng/mL (2021-05-24), 48ng/mL (2021-04-27), 63ng/mL (2021-03-30), 31ng/mL (2021-02-26), 0.8ng/mL (2020-07-17)
    • CA199 172U/mL (2021-05-24), 221U/mL (2021-04-27), 299U/mL (2021-03-30), 228U/mL (2021-02-26), 16U/mL (2020-03-24)
    • hs-Troponin I 109pg/mL (2021-07-17)
    • CRP 42mg/dL (2021-07-17)
    • Lactic Acid 3.5mmol/L (2021-07-17)
  • medication
    • UFT (tegafur 100mg, uracil 224mg) BID PO with Folina (folinate 15mg) BID PO since 2021-03-02.
      • the same drugs have been prescirbed shortly in Feb and May each for 28-day in 2017.
    • Flumarin (flomoxef sodium 1000mg) IVD Q12H

[assessment]

  • rectal cancer was first diagnosed in 2016, shortly thereafter followed with RT 5040cGy/28 and the disease has been controlled for not long years.
  • patient’s family have lost several relative elders these consecutive years, care burdens let the lineal descendent caregivers exhausted. hospice care is arranged.
  • oral prodrug of 5-FU for rectal cancer, lactulose for ileus, tramadol for pain control, ABX for UTI, no issue with the medication.
  • according to the time serial tumor markers level, the disease somewhat responded to 5-FU prodrug since 2021 March.
  • hs-Troponin I has played an important role in the risk stratification of patients during the in-hospital phase of acute coronary syndrome, the elevated level should be concerned.

[suggestion]

  • keep monitoring progresstion of the infection and signs of acute heart attack.
  • no adjustment for medication is needed.

700948740

210716

{potential interactions among lorazepam, olanzapine, morphine and labetalol}

[objective]

  • concurrent medication:
    • lorazepam 2mg IVD PRNQ4H
    • olanzapine 5mg PO HS
    • morpine 5mg IVD PRNQ4H
    • labetalol 25mg IVD PRNQ8H

[assessment]

[suggestion]

  • please monitor any sign such as anterograde amnesia, drowsiness, sedated stated, hypotension… to see if change is needed.

701300783

210716

==========

2021-07-08

{potential interaction when coadministering alprazolam, metoclopramide, olanzapine}

[objective]

the following items are listed in active medication: - alpraline (alprazolam, 0.5mg/tab) 1 tab PO HS - promeran (metoclopramide, 3.84mg/tab) 1 tab PO TIDAC - zyprexa zydis (olanzapine, 5mg/tab) 1 tab PO HS

[assessment]

  • metoclopramide might enhance the adverse/toxic effect of olanzapine.
    • this could associate with development of extrapyramidal reactions or neuroleptic malignant syndrome.
  • olanzapine might enhance the adverse/toxic effect of alprazolam.
    • due to risks of additive adverse effects (e.g., cardiorespiratory depression, excessive sedation).

[suggestion]

  • if any above suspected symptom is observed, please discontinue the coadministration.

2021-07-16

{potential interactions among alprazolam, olanzapine and zolpidem}

[objective]

  • concurrent medication:
    • alprazolam 0.5mg PO HS
    • olanzapine 5mg PO HS
    • zolpidem 10mg PO HS

[assessment]

[suggestion]

  • please monitor any sign such as drowsiness, fatigue, sedation, ataxia, memory impairment, irritability, cognitive dysfunction, dysarthria, dizziness to see if change is needed.

701239654

210706

{post-IPP meeting following up}

patient family meeting and IPP meeting was held at 10:00 on 2021-07-06

  • the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.

  • the estimated total amount of melphalan used in the time table is 6 vials.

    • based on melphalan 50mg/vial, dose 100mg/m2, body surface area 1.425m2.
    • 3 vials per day for 2 days (2021-07-07, 2021-07-08).
    • the amount has been secured by medicine storeroom.
  • preparation and administration precautions of mephalan:

    • expiration time 1.5hr after preparation (the duration including infusion time) according to package insert.
    • based on lab data reported on 2021-07-05, liver and kidney have no abnormality, no dose adjustment needed.

701243405

210630

[initial presentation]

  • 2021-05-07 intermittent lower abdominal pain for 3 weeks. pain was relieved after taking acetaminophen and diclofenac but recurred since 4 days ago. associated symptoms: constipation for 2 days, hiccup, nausea, poor appetite.

[definite diagnosis]

2021-05-06 CT - abd - loculated fluid accumulation at uterus up to 9.7*7.1cm in largest dimension is found. - uterine abscess is considered first. 2021-05-11 patho - ovary (tumor) - taiwan society of pathology was consulted to diagnose: malignant spindle cell and epithelioid cell neoplasm. - IHC: SALL4/BRG1/INI1(+), glypican/SATB2/cyclinD1( focal+); SS18-SSX/OCT4/CD30/ETV4/MDM2/S100/NUT/MyoD1(-).
- molecular pathology: SS18(-)(poor quality); chr12p/q FISH: failed. - comment: - while the majority of it was composed of relatively uniform spindle cells, gland-like components were also notable, in conjunction with the strong TLE1 immunostaining, justifying your original consideration of synovial sarcoma. - the degree of nuclear atypia would be somewhat too high for synovial sarcoma, and TLE1 expression is not specific. both SS18-SSX IHC and SS18 FISH performed to exclude this possibility. - given the gland-like structures which reminded yolk sac tumor, SALL4 (multifocally positive) and glypican (weakly positive, mainly in the gland-like structures) staining were performed and somewhat supported the speculation, albeit neither convincing nor specific enough. - attempt to pursue some molecular evidence of isochromosome 12p with chr12p, chr12q, and chr12 centromere FISH failed. - other possibilities including myoepithelial carcinoma were not supported by the current immunostaining results. - the case was reviewed by one senior GYN pathologist, one GU pathologist, and another soft tissue pathologist, and no conclusion could be drawn. - while a germ cell tumor with a component of yolk sac tumor and sarcomatoid transformation could not be excluded, the overall pathologic and clinical features would be atypical. - perhaps a genomewide study aiming at copy number variation/LOH might help in this regard. - note: some of the original immunostaining showed CK weak+, TLE1+, SMA f+, GFAP-. 2021-07-13 patho - ovary (tumor) - diagnosis: pelvic tumor, debulking surgery - compatible with recurrent malignant neoplasm. - the sections show a picture of spindle and epithelioid cell tumor characterized by spindle, ovoid or epithelioid tumor cells with congestion, hemorrhage, extensive necrosis, active mitoses, arranged in solid, focal fascicular or focal gland-like or rossette-like pattern, compatible with tumor recurrence.

[treatment]

  • 2021-05-10 debulking surgery (BSO + cytoreduction surgery + infracolic omentectomy + appendectomy) for malignant left ovarian tumor.
  • 2021-06-11 BEP (bleomycin + etoposide + cisplatin)
  • 2021-08-13 doxorubicin

==========

2021-06-30

{form virless (acyclovir) to famvir (famciclovir)}

[objective]

  • being diagnosed with herpes virus infection.
  • virless 500mg IVD Q8H ends by 2021-06-30 and famvir (famciclovir) 250mg PO TID starts from 2021-07-01.
  • ALT elevated few days ago, newer lab data reported on 2021-06-30 and 2021-06-28 showd liver and kidney function normal.

[assessment]

  • oral famciclovir excretion is primarily renal, and dose reduction is recommended in patients with impaired renal function.
    • no observed kidney problem, no adjustment need.
  • hepatic impairment

[suggestion]

  • please monitor the liver and kidney function as before, if liver function deteriorates, then adjust agent to maintain effect might be considered.

2021-06-28

{reported thrombotic microangiopathy with acyclovir}

[objective]

  • thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS), manifestations of thrombotic microangiopathy, have been reported with acyclovir/valacyclovir
    • source:
      • Bell WR, Chulay JD, Feinberg JE. Manifestations resembling thrombotic microangiopathy in patients with advanced human immunodeficiency virus (HIV) disease in a cytomegalovirus prophylaxis trial (ACTG 204). Medicine (Baltimore). 1997;76(5):369-380. doi: 10.1097/00005792-199709000-00004.
      • Bukhari S, Aslam HM, Awwal TA, Christmas D, Wallach SL. Valacyclovir-induced thrombotic thrombocytopenic purpura. Cureus. 2020;12(5):e8156. doi: 10.7759/cureus.8156.
      • Moake JL. Thrombotic microangiopathies. N Engl J Med. 2002;347(8):589-600. doi: 10.1056/NEJMra020528.
      • Trachtman H. HUS and TTP in children. Pediatr Clin North Am. 2013;60(6):1513-1526. doi: 10.1016/j.pcl.2013.08.007.
  • lab data
    • Bilirubin direct 0.06(6/28)
    • Bilirubin total 0.45(6/28)
    • S-GPT/ALT 59(6/28), 117(6/25)
    • Creatinine 0.67(6/28), 0.41(6/25)
  • acitve medication
    • virless (acyclovir) 500mg IVD Q8H
    • imperan (metoclopramide) 10mg IVD PRNQ6H
    • loperamide 2mg PO PRNQ6H

[assessment]

  • thrombotic microangiopathy mechanism:
    • idiosyncratic; leading to intravascular platelet-fibrin microthrombi, vascular damage, hemolysis, and thrombocytopenia. in HUS, this injury is believed to be initiated by uncontrolled activity of the alternative complement pathway, while TTP features a reduction in activity of ADAMTS13, the metalloprotease responsible for cleaving ultra-large von Willebrand factor multimers.
    • source: Trachtman H. HUS and TTP in children. Pediatr Clin North Am. 2013;60(6):1513-1526. doi: 10.1016/j.pcl.2013.08.007.
  • bilirubin within normal range, no sign of TTP and HUS in nursing records.
  • urinary retention and constipation could caused by herpes viral infection of the S2-S4 dermatome. accouding to active medication and nursing record, these should not be an issue.
  • liver function improved based on lowered ALT data, creatinine elevated but still in normal range.

[suggestion]

  • keep current medication, acyclovir prescription will be end on 6/30, please continue to prescribe if the condition need.

2021-06-24

{acyclovir to treat herpes virus infection in HBV active carrier}

[objective]

  • Lab
    • 2021-06-23
      • S-GOT/AST 68U/L
      • S-GPT/ALT 103U/L
      • creatinine 0.47mg/dL
      • eGFR 151
    • 2021-05-17
      • Anti-HBc Reactive
      • Anti-HBs 41mIU/mL
  • Medication
    • baraclude (entecavir) 0.5mg PO QD
    • virless (acyclovir) 500mg IVD Q8H

[accessment]

  • AST within 2x ULN, ALT within 3x ULN, liver function not so good but far from failure.
  • renal function tests showed no abnormaility.
  • the major route of acyclovir elimination is the renal excretion of unchanged drug (> 85%). liver plays no major roles in metabolism.
  • acyclovir can inhibit hepatitis B viral replication especially using higher dose.
  • acyclovir and its alternatives, e.g. cidofovir, foscarnet, ganciclovir, all need to be adjusted dose based on CrCl but not on liver function.
  • possible adverse reactions
    • acyclovir: acute renal failure, neurologic toxicity.
    • entecavir: increased serum alanine aminotransferase. (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), increased serum creatinine (1% to 2%)
  • there is no drug interaction of risk level A or greater identified between acyclovir, entecavir and current chemo regimen.

[suggestion]

  • regularily monitor liver and kidney functions the same as before, no adjustment needed.

701304862

210625

{potential abx absorption problem}

[objective]

  • active medication including:
    • Cravit (levofloxacin 500mg/tab) 1.5tab PO QDAC
    • Smecta (dioctahedral smectite 3gm/k) 1pk PO TIDAC
  • the above items used at the same time in the morning.

[accessment]

  • the adsorbent properties of smecta may interfere with the rates and/or levels of absorption of other substances, e.g. cravit.

[suggestion]

  • it is recommended not to administer any other drugs at the same time as smecta.
  • cravit could be shifted to HS to decouple administration time and still keep the same daily dose.

700373891

210618

{tube feeding}

all the oral drugs in active medication have been reviewed, the following two items can be peeled half but should not be grinded: - Curam (amoxicillin 875 mg, clavulanic acid 125 mg, tab) - film coated - Pentop (pentoxifylline 400mg, tab)

and the following item can not be peeled half or grinded: - Nexium (esomeprazole 40mg, tab)

the alternatives to above items, respectively, could be: - Soonmelt (amoxicillin 500mg, clavulanic acid 100mg, vial), if half-peeled Curam still too big to be fed. - there is no other drug containing same active ingredient with Pentop in the inventory, so please peel it (not too fine) to fit the tube. - Takepron (lansoprazole 30mg, tab) should not be grinded but can be peeled half.

701275722

210524

{tube feeding}

all the oral drugs in active medication can be administrated via NG tube except following items which should not be grinded:

  • nexium (esomeprazole): please dissolve it with adequate drinking water prior to tube feeding.
  • protase (pancrelipase): please open the capsule and mix the granules with pH<5.5 liquid food prior to tube feeding.
  • oxynorm (oxycodone): if injection is not preferred, then fentanyl patch such as ‘durogesic d-trans’ or ‘fentanyl transdermal path PPCD’ might be an alternative.

700061689

210517

{tube feeding}

the oral drug takepron (lansoprazole, 30mg/tab) in active medication should not be grinded, while it can be peeled in half.

there is also an iv version takepron (lansoprazole, 30mg/vial) can be the alternative.

700990347

210513

{Tube Feeding}

all the oral drugs in current medication can be administrated via NG tube.

actein effervescent (acetylcysteine) should not be grinded, please dissolve the drug in adequate amount of drinking water prior to tube feeding.

700072580

210512

{post IPP meeting following up}

  • the schedule with regimen for PBSCT for the patient is disclosed in the meeting.

  • the estimated total amount of busulfan used in the time table is 15 vials.

    • based on busulfan 60mg/10mL/vial, dose 3.2mg/kg, body weight 85kg
    • 5 vials per day for 3 days (2021-05-12, 2021-05-13, 2021-05-14)
    • pharmacy staff in charge of drug purchasing will get the inventory ready before the coming prescribing.
  • people for dispensing regimen during weekend are also arranged.

  • preparation and administration precautions:

    • busulfan:
      • do not use polycarbonate syringes or polycarbonate filter needles with the drug.
    • etoposide:
      • precipitation may be exacerbated at concentrations of 0.4 mg/mL or above.
      • etoposide 400mg/m2 x body surface area 2m2 -> amount 800mg.
      • total solution containing 800mg etoposide will be no less than 2000mL.

701284346

210512

{drug identification}

requesting drug identification for 6 items.

the 4 identified items has been shown as following while the other 2 items still remain unknown: - sinemet (carbidopa 25mg, levodopa 100mg) - urief (silodosin 4mg) - rivotril (clonazepam 2mg) - through (sennoside 12mg)

these drugs will be sent back to ward by the in-hospital porter.

700150240

210510

{problem list}

the active problems listed in the TPR sheet are shown as following:

  • pneumonia
  • UTI
  • hypertension
  • ileus
  • hyponatremia

[objective]

  • urine OB 1+ (2021-05-08)
  • urine bacteria 1+ (2021-05-08)
  • CRP 5.39 (2021-05-08)
  • D-dimer 1763ng/mL (2021-05-08)
  • hs-Troponin I 49pg/mL (2021-05-08)
  • Na 121mmol/L (2021-05-08)
  • BUN 57mg/dL (2021-05-08)
  • Creatinine 1.71mg/dL (2021-05-08)
  • WBC 15.55 (2021-05-08)
  • RBC 2.68 (2021-05-08)
  • MCV 97.4 (2021-05-08)
  • serum glucose 177mg/dL (2021-05-08)
  • no defecation recorded in these 2 days

[assessment]

  • vital signs, including blood pressure, looks relatively stable.
  • if no other special consideration exists, the first priority should be controlling the infections.
  • brosym 2000mg IVD Q12H has been prescribed to control the infection since 2021-05-09.
  • the lower serum sodium might be improved by intaking salted food.
  • lab data showed a higher serum glucose level, an one-point datum might not lead to its trend, more data to form a time series of blood sugar monitoring is recommended.
  • MCV almost touched the upper limit of the normal range, some folic acid and/or vit B12 supplements might be helpful for the mild anemia.
  • some laxative agent might be helpful for the ileus.

[suggestion]

  • keep abx using and monitoring changes of infection signs.
  • invite dietitian to help the patient to eat more salted diets and to see if any other diet issue found, then get sodium tested few days later.
  • order regular scheduled blood sugar tests to build its trend.
  • folacin (folic acid 5mg) and/or kentamin (thiamine 50mg, pyridoxine 50mg, cyannocobalamin 500mcg) are available in pharmacy inventory now, each of them could be administrated QD or BID, which is recommended.
  • if still no defecation before 2021-05-11, then dulcolax (bisacodyl 5mg) QD or BID could be considered to prescribe, and administrated until defecation or 3 days then reevaluate the condition.

700350999

210510

{problem list}

active problems listed in 2021-05-08 14:14 DutyNote containing 2 items: - urinary tract infection - right lower lung pneumonia

[subj/obj]

  • admitted on 2021-05-08 for lethargy, weakness for 5 days and fever for 1 day.
  • with underlying HFrEF, bladder cancer s/p TURBT, HCVD, CKD and DM, been regularly followed up at our cardiology, urology, metabolism departments.
  • bladder cancer causing voiding difficulties and UTI
  • K 3.1mmol/L (2021-05-10), 3.1mmol/L (2021-05-08)
  • BUN 123mg/dL (2021-05-10), 101mg/dL (2021-05-08)
  • Creatinine 4mg/dL (2021-05-10), 3mg/dL (2021-05-08)
  • eGFR 15 (2021-05-10), 20 (2021-05-08)
  • CRP 8.63 (2021-05-10), 5.31 (2021-05-08)
  • RBC 4x10^6/uL (2021-05-10), 3.7x10^6/mL (2021-05-08)
  • HGB 11.6g/dL (2021-05-10), 10.8 (2021-05-08)
  • MCV 84.8 fL (2021-05-10), 86.2 fL (2021-05-08)
  • urine OB 2+, sediment-RBC 6-9, sediment-WBC >= 100, Bacteria 3+ (2021-05-08)
  • hs-Troponin I 385pg/mL (2021-05-08)
  • serum glucose 177mg/dL (2021-05-08), records fluctuate between 126-226 from 2021-05-08 19:00 to 2021-05-10 11:30.
  • HbA1c 8.1 (2021-04-27), 8.6 (2021-03-01), 10.1 (2020-12-11), 9.6 (2020-09-17), 9.8 (2020-06-24)
  • Uric Acid 4.6mg/dL (2021-03-01), 6.1 (2021-01-19), 8.1 (2020-12-11), 9.3 (2020-09-17), 8.6 (2020-06-24)

[assessment]

  • vital signs looks relatively stable:
    • body temp no more than 37.5 degrees Celsius since 2021-05-08, the fever has subsided.
    • most of time SBP ranges in around 120-130, DBP 60-80, 3-day data showed BP is under well management.
  • if there is no other special consideration, the first priority should be controlling the infections.
    • avelox (moxifloxacin) 400mg IVD QD has been administrated since 2021-05-09 and scheduled till 2021-05-15.
    • the patient has poor renal function, but no dosage adjustment necessary for avelox administration.
  • although fever has gone, the rising CRP might hint the infection is still ongoing.
  • the lower serum potassium might caused by uretropic (furosemide).
  • lab data showed that blood suger flucturates in short-term (serum glucose), however the management is getting better in mid-term (HbA1c).
    • using humalog mix50 pen (insulin lispro 50%, insulin lispro protamine 50%) QDAC and QNAC now.
  • MCV almost touched the lower limit of the normal range, some iron supplements might be helpful for boosting up the hemoglobin level.
  • uric acid seems fell into normal range for months, xanthine oxidase inhibitor could be no more necessary.

[suggestion]

  • keep abx using and monitoring any change of infection signs.
  • invite dietitian to help the patient to get more potassium-containing food, and/or consider to shift uretropic (furosemide) to potassium sparing spironolactone.
  • foliromin (ferrous sodium citrate, 50mg) BID for 2-4 weeks to levelup hemoglobin is recommended, administrated in combination with vit C to help absorption can be considered.
  • if there is no special consideration, discontinuation feburic (febuxostat) is recommended.

700385854

210507

{colon cancer}

[subj/obj]

  • diagnosed with sigmoid adenocarcinoma in 2020 Apr with liver, paraaortic LNs, and peritoneal carcinomatosis, cT3N2bM1c, stage IVc.
  • received FOLFIRI 80% dose and 11 times panitumumab from May to Oct in 2020 at Taoyuan General Hospital of Ministry of Health and Welfare.
  • patho colon biopsy on 2020-11-26 showed one huge tumor was noted at sigmoid colon (30cm from anal verge) and the lumen was near completely obstructed.
  • colonic tissue with invasive irregular neoplastic glands. immunohistochemical stains reveal CDX2(+) EGFR(+), PMS2(+), MLH1(focal +), MSH2(+), and MSH6(+).
  • received FOLFIRI 6 times from 2020 Nov to 2021 Mar (C1D1, C1D15, C2D1, C2D15, C3D1, C3D15) in our hospital prior to this hospitalization.
  • NRAS/KRAS reported on 2020-12-15 showing not detected.
  • CEA 16.62ng/mL(2021-01-26), 8.52ng/mL(2020-11-17).
  • BRAF lab data not found.

[assessment]

  • patients with tumors originating on the right side of the colon (hepatic flexure through cecum) are unlikely to respond to cetuximab and panitumumab in first-line therapy for metastatic disease.
  • EGFR(+), KRAS/NRAS WT gene and left-sided tumor - panitumumab is purchased and will be ready for the patient in days.
  • immune checkpoint inhibitors might not an ideal option for non-dMMR/MSI-H tumor - MLH1(focal +), MSH2(+), MSH6(+).
  • according to CEA lab data, the condition might not be improved after one year FOLFIRI.

[suggestion]

  • might order CT scan to gather new evidence on treatment effect.
  • If evidence shows that the cancer is getting more advanced, then shift FOLFIRI to FOLFOX or CAPEOX (each regimen can be used in combination with bevacizumab) could be considered.

{substance dependence}

[subj/obj]

  • lab test showed evidence of using addictive drug.

[assessment]

  • should help the patient get rid of those illegal drugs.

[suggestion]

  • might arrange or refer the patient to an addiction treatment center or clinic to get some alternative e.g. methadone.

{returning to society}

[subj/obj]

  • his family members avoid to contact him.
  • no job, no income
  • not standing on his own feet yet (financially)

[assessment]

  • being not reintegrated to the society will push him closer to the additive drugs.

[suggestion]

  • might arrange social work department staff to see if any help could be offered to him.

700134931

000000

{colon cancer}

[initial presentation]

  • 2021-01-22 RBC 3.42x10^6/uL, HGB 6.6g/dL, blood transfusion pRBC 2U on 2021-02-12.
  • 2021-02-19 stool occult blood: positive

[definite diagnosis]

  • 2021-03-15 colonoscopy: probable advanced colon cancer, ascending colon, ileocecal valve involvement suspected
  • 2021-03-19 patho: adenocarcinoma, IHC stain: EGFR(+), PMS2(-), MLH-1(-), MSH-2(+), MSH-6(+)

[disease extent & staging]

  • 2021-03-16 CT, ABD:
    • low density lesions at both lobes of liver is found. liver simple cysts are considered.
    • compatible with ascending colon cancer, regional lymphadenopathy, T2N2aMo -> M1 (with liver mets)

[treatment & plan]

  • biweekly, Q2WK
    • covorin (leucovorin) 400mg/m2, with 250mL N/S, 2hr
    • 5-Fu (fluorouracil) 400mg/m2, with 100mL N/S, 10min
    • 5-Fu (fluorouracil) 2400mg/m2, with 500mL N/S, 46hr

[effect & side effect]

  • NA

[ongoing problem]

  • chronic ischemic heart disease
  • type 2 diabetes mellitus
  • hypercholesterolemia
  • polyosteoarthritis

700180657

000000

{colon cancer}

[objective]

  • 2018-02 diagnosed with adenocarcinoma of S-colon, cT3N0M0.
  • 2018-02-14 pathology
    • large intestine, sigmoid colon, laparoscopic LAR —- Adenocarcinoma, moderately differentiated.
    • IHC stains: EGFR (+), PMS2 (+), MSH 6 (+), MSH2 (+), MLH1 (+).
    • foci of mesenteric endometrosis, CK7 (+) and CK20 (-), with fibrosis.
    • AJCC 8th ed. staging: pT3N0 (cMx); pStage: IIA at least (if cM0).
      • primary tumor pT3 - tumor invades through the muscularis propria into pericolonic tissues
      • regional lymph nodes pN0 - no regional lymph node metastasis
      • distant Metastasis pMx
  • 2018-12-25 CT: soft tissue mass with necrotic margin at surface of uterus up to 2.9cm in largest dimension which is new in comparison to CT dated on 2018-06-02.
  • 2019-01-03 PET
    • a glucose hypermetabolic lesion on the superior aspect of the uterus. should be malignancy with pelvic seeding on the uterus.
    • increased FDG accumulation in the right lateral aspect of the abdomen and pelvic region and in the anterior aspect of the pelvic region.
  • 2019-01-04 sigmoidfiberscopy: an ulcerative tumor, about 1/3 circumferential bowel lumen at 18cm above AV (RS-colon) with easy contact bleeding previous anastomosis (10cm AAV) looked well.
  • 2019-01-10 low anterior resection (LAR) and hysterectomy plus bilateral salpingo-oophorectomy (BSO) recurrent 3cm tumor (favor seeding) involving uterus and upper rectum and a segment of small bowel was identified.
    • IHC stains: CK20(+), CK7(focal+), vimentine(-)
    • patho: rT4bN0M1a, stage IVA. 2019-09-20 received 12th Avastin & 14th FOLFOX6, mild fingers and feet numbness, pigmentation on breast skin. 2019-10-15 refilled Xeloda (capecitabine), mild fatigue, nausea, abdomen discomfort. 2019-11-26 refilled Xeloda (capecitabine), nail and finger pigmentation, mild fatigue and numbness. 2020-03-25 CT: a known newly-developed soft tissue nodule measuring 0.6 cm in right pelvic wall is noted again, increasing in size. 2020-04-07 PET
    • a glucose hypermetabolic lesion in the right anterior pelvic wall, compatible with a metastatic lesion.
    • multiple glucose hypermetabolic lesions in the left lower abdomen and in the pelvic cavity and a glucose hypermetabolic lesion in the left upper abdomen. 2020-11-07 CT: multiple soft tissue nodules in the peritoneum (upper abdomen and pelvic cavity), up to 1.7cm in left pelvic cavity, suspected peritoneal carcinomatosis. 2021-02-20 CT: progression of peritoneal tumors with left lower ureter invasion causing left hydronephrosis and hydroureter.
  • CEA
    • 2021-04-28 _8.64
    • 2021-03-29 15.23
    • 2021-03-02 16.89
    • 2021-01-23 13.56
    • 2020-10-28 _5.044
    • 2020-06-22 12.062
    • 2020-03-18 _8.714
    • 2019-12-09 _2.008
    • 2019-08-16 _0.866
    • 2019-04-30 _1.534
    • 2018-12-10 15.635
    • 2018-09-10 _2.047
  • regimen
    • 2018-03-03 ~ __________: Ufur (tegafur + uracil)
    • __________ ~ 2020-07-03: FOLFOX + Avastin (bevacizumab)
    • 2020-07-17 ~ 2021-02-19: FOLFIRI + Cyramza (ramucirumab)
    • 2021-03-31 ~ up to now : RegoNivo (Opdivo (nivolumab) + Stivarga (regorafenib))

[assessment]

  • PMS2 (+), MSH 6 (+), MSH2 (+), MLH1 (+) -> not dMMR, EGFR (+), pembrolizumab might not be indicated.
  • no KRAS/NRAS/BRAF lab data found.
  • after using 5-FU, FOLFOX plus anti-VEGF bevacizumab as adjuvant first-line therapy for more than one year (2018 Mar ~ 2020 Jul), the disease progressed, then the regimen was shifted to FOLFIRI plus anti-VEGFR2 ramucirumab as second-line therapy. the two regimen are listed in NCCN clinical practice guidelines.
  • the cancer has been progressed in 2020Q4 ~ 2021Q1, regimen shifted to RegoNivo since end of 2021 March.
    • nivolumab - anti-PD1, usually used in combination with anti-CTLA4 i.e. ipilimumab, to treat adults with metastatic colorectal cancer that is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR), and patient have tried treatment with a fluoropyrimidine, oxaliplatin, and irinotecan.
    • regorafenib inhibits multiple kinases including VEGF1, VEGF2, VEGF3, PDGFR, FGFR involved in tumor angiogenesis and KIT, RET, RAF-1, BRAF involved in oncogenesis.
    • RegoNivo regimen is supported by articles, e.g. “Regorafenib Plus Nivolumab in Patients With Advanced Gastric or Colorectal Cancer
  • possible toxicity for RegoNivo regimen
    • nivolumab can result in significant immune-mediated adverse reactions due to T-cell activation and proliferation. These immune-mediated reactions may involve any organ system, with the most common reactions being pneumonitis, enterocolitis, hepatitis, dermatitis, hypophysitis, nephritis, and thyroid dysfunction.
    • regorafenib:
      • hypertension occurs in nearly 30% of patients. usually occurs within 6 weeks of starting therapy and is well controlled with oral antihypertensive medications.
      • skin toxicity in the form of hand-foot syndrome and skin rash occur in up to 45% and 26%, respectively. generally appears within the first cycle of drug treatment.

[suggest/plan]

  • monitor any sign of toxicity caused by nivolumab and regorafenib.
  • keep tracking tumor markers including CEA
  • update chest, abdomen, and pelvic CT (and/or PET) every 3-6 months.

700290223

000000

{intrahepatic cholangiocarcinoma}

[initial presentaion]

  • 2006-04 Echo
    • Liver cirrhosis (HCV related), liver cysts status post left lobectomy
    • Parenchymal renal disease with bilateral renal cysts, GB polyps, multiple
  • 2008-10 HCC s/p operation left lobectomy
  • 2010-03-03 Recurrent HCC in S6 s/p S6-segmentectomy

[definite diagnosis]

  • 2021-04-09 Patho liver biopsy
    • adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma
    • IHC: CK7(+), CK20(focal+), Hepa-1(-) and Arginase-1(-)

[disease extent]

  • cT2N0M0, stage II

[treatment]

  • 2021-05-26 ~ 2021-05-20 CCRT 3240cGy/18 fractions, gemcitabine

[effect and side effect]

  • 2021-07-13 CT, ABD
    • s/p op. over left lobe liver with residual choalangiocarcinoma at S4 and liver meta.
    • the ovarall treatment response is stationary except slghtly increaed metastatic size.
    • gallstones.

[ongoing problem]

HCV, Cirrhosis, Child A - 2021-03-30 - HBsAg Nonreactive - Anti-HBc Reactive - Anti-HCV Reactive

hypertention, portal hypertension varicose vein GERD type 2 DM

700348580

000000

  • 2018-10 diarrhea on and off

  • 2020-11-12 patho - colon biopsy

    • pieces of colonic tissue with invasive irregular neoplastic glands.
    • immunohistochemical stains - EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2020-11-12 CT, ABD: cT3N2aMia, stage IVA Re-evaluation on 12/14/2020 slightly decreased in tumor size.

  • 2020 late Nov ~ 2021 early Jan CCRT, FU/LV 5040 cGy/28Fx in hope of receiving sphincter preserving surgery (Last RT on 1/5).

  • 2021 Feb there after chemo FOLFOX

  • 2021-02-18 CT, ABD: much regression of rectal cancer.

2021-03-10 Op Method: Abdominoperineal resection (APR)
Finding: 1. Tumor in rectum, cT3N2aM1a (enlarged nodes in left external iliac chain) 2. End S colostomy is done over LLQ
3. One JV drain at pelvic area

rectal cancer, cT3N2aM1a s/p CCRT, was admitted for scheduled laparoscopic APR with permanent colostomy. - 2021-03-18 patho - abdomino-perineum resection - ypT3N1aMia stage IVA

2021-05-13 Self-Monitoring of Blood Glucose,SMBG QDAC

PatMRNo, PatID, PatName, PatBDate, PatGender

Brosym 4g Q12H

assumed 50kg body weight with Cockcroft-Gault formula, the estimated CrCl is 25mL/min, daily maximal dose is 4g (2g Q12H) according to package insert.

cefoperazone sulbactam

daily maximal 4g (2g Q12H)

Nexium (esomeprazole) should not be grinded, shifting to Takepron (lansoprazole) is recommended.

Actein should be dissolved in adequate drinking water prior to tube feeding.

thanks and regards,

all the oral drugs in active medication can be administrated via NG tube except Doxaben XL (doxazosin) which is release-controlled.

Urief (silodosin) is recommended as an alternative to switch Doxaben.

thanks and regards,

omeprazole lansoprazole pantoprazole rabeprazole

700360779

000000

[objective]

  • exam finding
    • 2022-05-02 Chest AP portable
      • right internal jugular central venous catheter with tip in the SVC
      • normal size of heart
      • residual hazy areas of increased opacity with reticular opacities in Lt lung and Rt lower lung zone
    • 2022-04-29 Renal ultrasound
      • Parenchymal renal disease.
      • Perirenal fluid accumulation over right lower kidney, suspected Inflammatory or infectious process.
    • 2022-04-21 CT - lung/mediastinum/pleura
      • Interstitial pneumonitis at both lungs.
      • Heart failure.
      • Calcified coronary arteries is found.
    • 2022-04-21 Cardiac ultrasound
      • normal chamber size
      • concentric LV hypertrophy
    • 2022-04-20 MRI - liver, spleen
      • Lobulated soft tissue lesions, passive atelectasis, or effusions in bilateral posterior basal CP angle are suspected. Please correlate with CT.
      • The liver and spleen shows hypointensity on T2WI that may be iron deposition. please correlate with clinical condition.
      • Artifact or fluid collection in right upper abdominal wall is suspected? Please correlate with CT.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
    • 2022-04-12 Standing KUB
      • Wedge deformity of L1 vertebral body is suspected. Please correlate with lateral view.
      • Spondylosis of the L-spine is noted.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
      • Fecal material store in the colon.
    • 2022-04-13 Electrocardiography
      • Sinus tachycardia with Premature atrial complexes with Aberrant conduction
    • 2022-04-01 CT - lung/mediastinum/pleura
      • Esophageal cancer at middle third esophagus with slightly decreased in size.
    • 2022-02-11 CT - lung/mediastinum/pleura
      • Esophageal cancer at middle third esophagus s/p trial with statonary primary tumor size and extension as well as the mediastinal lymph nodes s/p jejunostomy.
    • 2022-01-27 GI series
      • suspected esophageal rupture or ulceration at esophageal tumor, middle third esophagus.
    • 2022-01-11 CT - lung/mediastinum/pleura
      • middle third esophageal cancer, significant improvement and persisted multiple small LNs in visceral and left anterior prevascular spaces compared with CT on 2021/11/18.
    • 2021-12-29 Renal ultrasound
      • bilateral chronic change of both kidneys.
    • 2021-11-18 CT - lung/mediastinum/pleura
      • Esophageal cancer at middle esophagus with main tumor regression.
      • Lymphadenopathy in the mediastinum. Stable
      • s/p jejunostomy.
      • Calcified coronary arteries is found.
    • 2021-11-03 Standing KUB
      • Spondylosis of the L-spine is noted.
      • Disk space narrowing of L4/5.
      • Compression fracture of L1 vertebral body.
      • Fecal material store in the colon.
    • 2021-09-27 MRI - brain
      • No evidence of brain metastasis.
    • 2021-09-23 CT - lung/mediastinum/pleura
      • Esophageal cancer up to 8.9*2.95cm with regional and mediasitnal lymphadenopathy. Stationary as compared with previous CT on 2021-08-30.
    • 2021-09-09 Tc-99m MDP whole body bone scan
      • Mildly increased activity in the middle to lower T-spines and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some faint hot spots in bilateral rib cages and mildly increased activity in the right femoal neck. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, left hip, bilateral knees and left ankle, compatible with benign joint lesions.
    • 2021-09-08 Whole body PET scan
      • Glucose hypermetabolism in the middle esophagus, compatible with the primary malignancy of esophagus.
      • Glucose hypermetabolism in bilateral mediastinal lymph nodes, cancer with regional lymph nodes metastases should be considered, suggesting further investigation.
      • Increased FDG uptake in the right upper and right lower lungs, the nature is to be determined (inflammation/infection process or distant mets?), suggesting further investigation also.
      • Esophageal cancer, cTxN2M0-1, by this F-18 FDG PET/CT scan.
    • 2021-09-06 Patho - esophageal biopsy
      • Upper esophagus, biopsy — Severe dysplasia at least
      • Microscopically, the sections show a picture of severe dysplasia at least characterized by pleomorphic and hyperchromatic atypical squamous cells with focal ulceration, lymphoid follicle with germinal center, without convincing stromal invasion.
      • Immunohistochemistry of P16(-), P53(+), P63(+) and CK(+) for dysplastic cell. However, more advanced lesion can not be excluded entirely. Closely follow up and repeat biopsy is advised, if clinically indicated.
    • 2021-09-04 MRI - brain
      • no evidence of brain metastasis.
    • 2021-08-30 CT - lung/mediastinum/pleura
      • Imaging Report Form for Esophageal Carcinoma
        • Impression (Imaging stage): T4N2M0
    • 2021-08-30 Patho - esophageal biopsy
      • Diffusely circumferential mucosal erosions with frability were noted at upper esophagus(30cm~20cm below the inscisor). Upper esophageal tissue peel off spontaneously when endoscopy pass through it. We used net to removed it out and sent for pathology.
      • Upper esophagus, 30-20 cm below the incisor, peel removal — Squamous cell carcinoma
      • Immunohistochemistry shows CK(+), P63(+), P53(+) and P16(-) for tumor cell.
    • 2021-08-27 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Diffuse esophageal erosions with oozing, upper esophagus, s/p pathology evaluation
        • Esophageal ulcers, multiple, middle and low esophagus
        • Superficial gastritis
        • Suspect Brunner’s gland hyperplasia, bulb
      • Suggestion
        • Admission for observation
        • Endoscopic hemostasis for upper esophagus was difficult. Consider angiography if still active bleeding
        • Persue pathology result
  • consultation
    • 2022-04-29 General and Gastroenterological Surgery.
      • Q
        • For TPN
        • This 66-year-old man patient is a case of squamous cell carcinoma of upper to middle third esophageal with bilateral mediastinal lymph nodes metastasis, cT4aN2M1, Stage IVB s/p Port-A and feeding jejunostomy, s/p BGB-A317, BGB-A1217 and cisplatin plus 5-FU and chronic kidney disease, stage 3 (Creatinine 2.11 mg/dL). This time, for fever with B/S on 20220403 showed Enterococcus faecium and Acinetobacter baumannii complex infection and Port-A blood culture showed GPC. Remove Port-A on 20220408. Intabated ETT on 20220421 due to severe metabolic acidosis and dyspnea. Transferred to ICU for severe sepsis on 20220421. Jejunostomy created on 20210906. However, ostomy wound reddish and leak, so NPO since 20220425.
      • A
        • obj?
          • A case of esophageal cancer with j-tube leakage who request nutrition support.
          • General appearance: ill looking
          • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (+), Poor digestion (-), BW loss (-) , stool (+), Bowel sound (-)
          • Feeding: NPO
          • Allergy: NKA
          • Nutrition assessment: BH 164cm, BW 66.2kg, UBW 56.8 kg, IBW 59.2kg, 96% IBW, BMI 21, BEE (calculated based on IBW) 1251kcal, TEE 1952kcal
          • Lab data: Alb 2.9, BUN 26, Cr 0.58, Na 133, K 3.6, BS 100
          • According to the patient’s present conditions, parenteral nutrition plus enteral feeding (place ND tube if achieved as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
        • PN suggestion:
          • DC Bfluid 1000ml(RI 4U)and D10W 500ml(RI 12U)QD
          • DC D50W 80ml Q6H(RI 8U each time)
          • D50W 500ml QD run 20.8ml/hr(add RI 10U )
          • Amino-Hepa 1000ml QD
          • Lyo-Povigent 4ml/QD(add in TPN)(if out of stock, then use B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
          • Addaven 10ml/QD(add in TPN)
        • PN monitor items
          • Check BW QW5 and record I/O Q8H
          • Check one touch Q6H for 2days, if stable QD check
          • Please control BS < 200 mg/dl with RI sliding scale
          • QW1 check CBC/DC
          • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
          • if TPN not sufficient, use YF5 or D10W instead.
    • 2022-04-22 Rheumatology and Immunology
      • Q
        • For IVIG (autoimmune disorders)
        • Current problem: We need your specialist to evaluate and screen the patient, to exclude auto-immune disease or suitable administration of intravenous immune globulin (IVIG).
      • A
        • History review were performed. Patient was admitted to ICU due to acute respiratory failure after receiving check point inhibitor therapy for esophagus SCC. I was consulted for immunotherapy for possible drug-related ILD.
        • Suggestion:
          • Treatment as current your expert’s management and infection control.
          • For IVIG dosage (1-2g/kg), please prescribe IVIG 60g, divided by 3 days therapy as below:
            • Day 1:
              • N/S 250mL for 1 hour
              • IVIG 20gm (4 bots) in D5W 300mL(total 500mL) IVD for 6 hours
              • N/S 250mL for 1 hour
            • Day 2:
              • N/S 250mL for 1 hour
              • IVIG 20gm (4 bots) in D5W 300mL(total 500mL) IVD for 6 hours
              • N/S 250mL for 1 hour
            • Day 3:
              • N/S 250mL for 1 hour
              • IVIG 20gm (4 bots) in D5W 300mL(total 500mL) IVD for 6 hours
              • N/S 250mL for 1 hour
          • Consider to add actemra 1AMP (162mg) SC as adjunctive therapy for ILD.
          • Please monitor clinical condition after therapy. If not effective, then plasma exchange maybe considered.
    • 2022-04-22 Metabolism and Endocrinology
      • Q
        • For abnormal thyroid enzymes
        • Current problem: We need your specialist to evaluate and differential diganosis as sick euthyroid or medical advice.
      • A
        • O:
          • HR: 66-135
          • SBP: 110-200+
          • Possible related medication: methylprednisolone (since 20220418)
          • AST/ALT: 68/119
          • BUN/Cr: 69/2.88
          • Na: 142, K: 3.4
          • TSH/FT4: 1.952/0.58
          • FT3: 1.4
          • ATPO, ATG, TSH receptor Ab: unavailable
          • ACTH/Cortisol: 5.3/7.86 (20220419), steroid (+)
        • A: R/I sick euthyroid syndrome
        • Suggestions:
          • No need of any treatment at this timing
          • Recheck TSH/FT4 (biochemistry) 2 weeks later
    • 2022-04-21 Nephrology
      • Q
        • For AKI with metabolic acidosis
        • Current problem: HD is prefer, We need your specialist to evaluate.
      • A
        • Lab data:
          • PH: 7.18, PCO2: 29, PO2: 146, HCo3:10.8, BE: -16.2
          • WBC: 21.42, Hb:11.0, PLt: 346
          • CEA: 9.96, SCC:3.1
          • GPT: 224, GOT: 105, T.bil: 7.26, D.bil: 4.77, LDH: 330, lipase: 288, amylase: 150, rGT: 768
          • BUN/cre : 25/1.68 (20220330) -> 27/2.11 (20220404) -> 29/2.94 (20220414) -> 49/5.00 (20220418) -> 82/4.15(20220420)
          • U/O: 1420ml -> 56ml
          • Vital signs: E2V5M4, BP: 179/105mmHg
          • PE: Under MV ventilator FiO2: 60%, no limb edema
          • CT chest: interstitial pneumonitis at both lungs
          • Cardiac echo: LVEF 71.5%, concentric LVH
        • Impression:
          • Acute kidney injury stage 3 on CKD with metabolic acidosis
        • Suggestion:
          • Check serum lactate, ketone, Cl, FeNa, FeBUN, urine osmolarity, blood osmolality
          • Check Urine for analysis
          • Correct metabolic acidosis and follow up ABG
          • Adequate IV fluid hydration
          • Avoid nephrotoxic drugs
          • If there is refractory metabolic acidosis, electrolyte imbalance, fluid overload, oliguria, we will arrange RRT if family agree
        • 20220428 Follow up:
          • Still metabolic acidosis (nonAG)
          • Check urine AG and add sodium bicarbonate 2# bid
          • Arrange renal echo
          • We will follow up this case
    • 2022-04-19 Gastroenterology
      • Q
        • This 66-year-old man patient is case of squamous cell carcinoma of upper to middle third esophageal with bilateral mediastinal lymph nodes metastasis, cT4aN2M1, Stage IVB s/p Port-A and feeding jejunostomy, s/p BGB-A317, BGB-A1217 and cisplatin plus 5-FU.
        • This time, for progression abnormal liver function, R/O IO therapy side effect.
      • A
        • Rule out other possibilities before considering BGB-A317-, BGB-A1217-induced hepatitis.
          • Check ALKP, rGT, ALB, PT, APTT, LDH to complete liver study
          • Check Anti HAV IgM, HBsAg, anti-Hbs Ab, Anti HCV Ab
          • Check antinuclear antibodies (ANA), smooth muscle antibody (SMA), Epstein Barr virus (EBV) IgM, cytomegalovirus (CMV) PCR
          • Check thyroid and adrenal function
          • Regularly/closely monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALKP (every two days)
          • Avoid hepatic toxic agent if possible(or adjust dose), simplify medication
          • silymarin 1#~2# TID
        • When other possibilities have been excluded or the liver has decompensated and a checkpoint inhibitor-related immune hepatitis is suspected, steroids may be administered for immune-mediated hepatitis: (reference: Sanjeevaiah, A., Kerr, T., & Beg, M. S. (2018). Approach and management of checkpoint inhibitor-related immune hepatitis. Journal of gastrointestinal oncology, 9(1), 220–224. https://doi.org/10.21037/jgo.2017.08.14 )
          • Initial dose of 0.5 to 1 mg/kg/day of prednisone for Grade 2 hepatitis
          • Initial dose of 1 to 2 mg/kg/day of prednisone for Grade 3 or greater hepatitis, followed by a slowly taper about one month
          • Based on severity of liver enzyme elevations, withhold or discontinue BGB-A317, BGB-A1217
          • Consider liver biopsy for alternate etiology and add mycophenylate mofetil 1g PO BID if no improvement after 3 days of steroid
    • 2022-04-08 Infectious Disease
      • Q
        • This time, for fever with B/S on 20220403 showed Enterococcus faecium and Acinetobacter baumannii complex infection and Port-A blood/C showed GPC. Port-A catheter removed on 20220408.
      • A
        • The Enterococcus is susceptible to ampicillin.
        • The Acinetobacter is susceptible to pip/tazo.
        • Agree with your use of tapimycin. Adjust the dose to 2.25g iv q6h according to the renal function.
        • Recheck B/C 3 days later. Please consider to remove the port-A if persistent bacteremia.
        • Arrange CV-echo to exclude endocarditis.
    • 2022-03-16 Dermatology
      • This patient suffered from dyskeratotic nails for years.
      • Imp: Tinea unguim, subacute dermatitis
      • Suggestion:
        • Excelderm crema 2 tubes, bid
        • Topsym cream 4 tubes, bid
    • 2021-12-28 Nephrology
      • Q
        • Consultation for renal dysfunction (eGFR 20) and electrolyte imbalance (K 2.5, Mg 4, Ca 1.84, Na 126).
      • A
        • Impression:
          • AKI Stage 3, cause to be determined
          • Hypokalemia suspect extrarenal loss related
          • Hyponatremia suspect extrarenal loss related
        • Suggestions:
          • check FeNa, urine Na, urine osmo, urine K, urine Cl, urine creatinine, urine Mg
          • check blood osmo, cortisol, ACTH, thyroid functions, total CO2
          • potassium supplement
          • adequate hydration
          • record I/O and body weight qd
          • avoid nephrotoxic agents
          • keep hemodynamic stable
          • arrange renal echo
          • recheck electrolytes, renal functions and total CO2
    • 2021-12-24 Metabolism and Endocrinology
      • Q
        • For evaluate hypothyroidism therapy
      • A
        • O:
          • BH: 166 cm, BW: 61.1 kg
          • HR: 78-114
          • Possible related medication: nil
          • AST/ALT: 16/17
          • BUN/Cr: 94/3.30
          • Na: 140, K: 3.9
          • TSH/FT4: 7.543/1.00
          • FT3: 3.1
          • ATPO, ATG, TSH receptor Ab: unavailable
          • ACTH/Cortisol: unavailable
        • A: Subclinical hypothyroidism
        • Suggestions:
          • Check anti-TPO Ab, anti-thyroglobulin Ab, ACTH/cortisol
          • Recheck TSH/FT4
          • No need of thyroxine supplement at this moment
          • Endocrine OPD F/U
    • 2021-09-07 Hemato-Oncology
      • Patient examined anc Chart reviewed. A case of T4N2Mx, Stage IV ESCC is noted. I am consulted for further evalution and mangmenet.
      • My suggestions are:
        • Arrange discussion with patient and family (already the afternoon on 2021-09-11)
        • The patient is preliminarily fit the clinical trial of Phase I BGB at Cohort 6.
        • Please do not perform radiotherapy at present, which is requested by trial.
        • If necessary, I might take over this case.
    • 2021-09-02 Radiation Oncology
      • Subjective:
        • History: This 66-years-old male patient has been drinking alcohol for 30-40 years (half glass per day). He has suffered from progressive dysphagia and BW loss of 10 kg for 2 months. He can tolerate soft diet now. Due to the EGD showed suspicious esophageal lesion, r/i malignancy, chest CT on 2021/08/30 reported esophageal carcinoma, cT4N2M0. Pathology report showed squamous cell carcinoma, moderately differentiated. Staging workup is ongoing.
        • Previous RT: denied.
        • Other disease: Gastric ulcer with bleeding and hemorrhoid for 12 years.
        • Family history: denied.
        • Habit: smoking, 1 PPD for 30 yr, quitted for 15 yr; alcohol: half glass per day, just quitted; betel nut: denied.
        • Married. Caregiver: his wife. Job: retired buffet cook. No or mild economic stress.
        • Language: Mandarin, Taiwanese.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2021/09/02: No palpable SCF LNs.
        • Pathology: 2021/8/30, Upper esophagus, 20-30 cm below the incisor, peel removal — MD squamous cell carcinoma; CK(+), P63(+), P53(+) and P16(-).
        • Images:
          • PED, 2021/8/30: diffusely circumferential mucosal erosions with friability were noted at upper esophagus (20cm~30cm) below the incisor. Upper esophageal tissue peel off spontaneously when endoscopy pass through it. We used net to removed it out and sent for pathology. Multiple ulcers were noted at middle and lower esophagus (from ECJ to 30cm below the incisor). Mucosal active oozing was noted at 23cm below the incisor.
          • Chest CT, 2021/08/30: asymmetric esophageal wall thickening of middle third of thoracic esophagus with severe luminal narrowing (length 7.5 cm, thickness 30 mm), with loss of fat planes between posterior wall of trachea and left main bronchus. multiple small LNs in visceral and left anterior prevascular spaces. Hila: no enlarged LN. IMP: middle third esophageal cancer cT4N2. Nonspecific inflammation in LUL. Moderate 3V-CAD.
          • EUS, 2021/9/03: pending.
          • Bone scan, PET, 2021/9/06: pending.
      • Diagnosis: Esophageal cancer, M/3, MD SqCC, cT4N2M0 (pending staging workup) with loss of fat planes between posterior wall of trachea and left main bronchus, R & L paratracheal and subcarinal LAP metastasis; ECOG = 1.
      • Suggest: Radiotherapy.
      • Goal: Curative (pre-operative).
      • RT Plan:
        • Target & Volume: Esophageal tumor and LAPs.
        • Technique: VMAT & IGRT by linear accelerator.
        • Dose & Fractionation: 5040cGy/28 fractions with concurrent chemotherapy.
      • Plan: Staging workup, PortA implantation and jejunostomy are suggested. CCRT is suggested for downstage & downsize. Possible radiation effects (malaise, radiation esophagitis, pneumonitis) is told. CT simulation will be arranged on 20210908 after PortA implantation and jejunostomy are done. Diet education is given.
  • surgical operation
    • 2022-01-24 Endoscopic esophageal dilatation
      • esophageal stenosis noted around 25~30 cm from incision
      • tumor resolution noted at endoscopic view
      • esophageal perforation at 9’ clock 25 cm from incision due to fragile esophageal wall
      • dilatation successful upto 48 Fr. Bougie dilator
    • 2021-09-06 Feeding jejunostomy + port-A insertion
  • chemoimmunotherapy
    • 2022-02-04, -02-18 - tislelizumab + ociperlimab
    • 2021-11-03, -11-24, -12-15 - fluorouracial + cisplatin + tislelizumab + ociperlimab
    • 2021-10-13 - fluorouracil + cisplatin

700935936

000000

{rectal cancer}

  • rectal cancer s/p LAR, pT3N0M0, stage IIA

[initial presentation]

  • 2019/2020 bowel habit change, bloody stool, mucus stool, tenesmus
  • 2020 2nd half iFOBT(+)
  • 2020-10-29 colonscopy showed one mass in the rectum 10cm from anal verge

[definite diagnosis]

  • 2020-11-04 patho outcome
    • adenocarcinoma: section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2020-12-17 NRAS/KRAS not detected.

[disease extent & staging]

  • 2020-11-04 CT, ABD: cT3N2aM1a, IVA
    • there is soft tissue nodule in LLL of the lung.
    • there is a suspicious soft tissue nodule in RLL of the lung.
  • 2020-11-23 patho: pT3N0, stage IIA (if cM0)
    • Histology: Adenocarcinoma
    • Histology Grade: G2: moderately differentiated
    • Angiolymphatic invasion: present
    • Perineural invasion: present
    • LLL nodule, frozen section: intrapulmonary lymph node (0/1) with anthracosis

[treatment]

  • 2020-11-18 3D VATS wedge resection
    • one nodular lesion was noted over LLL, size about 0.5cm in diameter.
    • frozen section showed benign lesion.
  • 2020-11-18 Robotic-assist low anterior resection
  • 2020 Dec CCRT 4320cGy/24 with 5FU(400mg/m2)/LV(20mg/m2)
  • 2021 Jan CCRT 5400cGy/30 with 5FU(400mg/m2)/LV(20mg/m2)
  • 2021 Feb thereafter biweekly FOLFOX
  • 2021-06-01 CT: no evidence of recurrent/residual tumor in the study.

[effect & side effect]

  • updated CT on 2021-06-01 shows current treatment still works
  • no side effect graded more than CTCAE grade 1 is found
  • active medication reviewed without issue:
    • metoclopramide, prophylaxis or treatment of nausea and vomiting associated with emetogenic cancer chemotherapy
    • clonazepam, for anxiety disorder or rapid eye movement sleep behavior disorder
    • sennoside, laxative/stimulant for constipation
    • acetylcysteine, mucolytic agent

[ongoing problem]

  • suspected covid-19 resolved
    • 2021-05-25 rapid test positive
    • 2021-05-26 real-time pcr negative

701057711

000000

  • D-colon cancer obstruction s/p self expandable metalic stent placed on 2020-07-16, and single-incision laparoscopic surgery (SILS) with left hemicolectomy on 2020-07-22
  • patho colon segmental resection for tumor reported on 2020-07-28:
    • tumor, descending colon, laparoscopic low anterior resection (LAR) - adenocarcinoma
    • lymph node, mesocolic, dissection - Tumor metastasis (2/16) without extracapsular extension (0/2).
    • AJCC pathologic staging pT4aN1b (if cM0), stage IIIB.
    • histology grade G2: moderately differentiated with focal tumor necrosis, abscess and mucin production.
    • ImmunoHistoChemistry for tumor cells: EGFR(+, 100%), PMS2(+), MLH1(+), MSH2(+) and MSH6(+).
  • mFOLFOX6 adjuvant chemotherapy 12 cycles from 2020-08-14 to 2021-01-22.
  • metastatic adenocarcinoma over left lower lung status post video-assisted thoracic surgery left lower lung wedge resection on 2021-02-26.
  • shift chemo regimen to FOLFIRI since 2021-03-26.

Decreased chemotherapy dose to 67 % for grade 3 diarrhea with blody weight loss. Decreased chemotherapy dose to 75 % for grade 2 diarrhea with blody weight loss.

701257485

000000

  • Hx: chronic viral hepatitis B without delta-agent
  • 2020-10-22 abdominal fullness without stool passage for days, lower abd mass with ascites -> CT: focal wall thickening at sigmoid colon and descending colon junction with severely dilated proximal colon and ileum is found. colon cancer with obstruction is considered.
  • 2020-10-23 sigmoidoscopy: one mass was noted in the DS colon with near total obstruction Size 3.6 cm. ( 50 cm from anal verge) s/p 9-cm stent under fluoroscopy.
  • 2020-11-10 patho: colon, descending-sigmoid, left hemicolectomy - adenocarcinoma, moderately differentiated.
    • IHC stain: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+).
    • tissue labeled as ‘gastric superficial lesion’, biopsy - metastatic carcinoma.
    • staging: pT3pN0pM1c, pStage IVC.
  • regimen
    • 2020-11-27 ~ 2020-12-15, _3 times: FOLFIRI
    • 2020-12-29 ~ 2021-05-13, 11 times: FOLFIRI + Avastin (bevacizumab)

701263241

000000

701263241__999999__MNote

{colon cancer}

[objective]

  • 2019-05-21 colonoscopy: one ulceative mass lesion with lumen stenosis over 15 cm from anal verge, patho - adenocarcinoma.

  • 2019-06-12 laparoscopic anterior resection and partial cystectomy, findings:

    • sigmoid cancer with direct invasion to urinary bladder, enlarged LNs, and extraserosal surface invasion, but no peritoneal seedings, no liver surface lesion.
    • poorly differentiated, signet ring cell (+), lymphovascular invasion (+), perineural invasion (+), LN (+, 10/16), urinary bladder margin (+), pericolorectal tissues (+), MSH-6 intact, PMS-2 intact
    • ATCC 8 pT4bN2bMx, stage IIIC (if M0).
  • 2019-09-10 CT: recurrence over left pelvis, and omentum of LLQ.

  • stayed in USA for months, lost following up in Taiwan health care provider.

  • 2021-01-04 CT abdomen: colon cancer s/p operation with peritoneal carcinomatosis with massive ascites, T0N0M1c, Stage IVC.

  • 2021-04-06 CT abdomen, pelvis:

    • massive ascites with suspected omental cake is found.
    • the severity of the ascites is stationary.
    • right pleural effusion, probably reactive pleural effusion.
  • 2021-04-16 ascites tapping: 3075cc clear yellowish ascites was drained.

  • 2021-04-20 cyto, ascites: smears show clusters of pleomorphic tumor cells. the morphology is consistent with metastatic adenocarcinoma.

  • CEA

    • 2021-05-04 46.48ng/mL
    • 2021-04-13 36.13ng/mL
    • 2021-03-22 26.25ng/mL
    • 2021-02-02 27.45ng/mL
    • 2020-12-15 22.34ng/mL
  • CA199

    • 2021-05-04 8.51U/mL
    • 2020-12-15 8.63U/mL
  • CA125

    • 2021-04-13 115.4U/mL
    • 2021-03-22 _56.6U/mL
    • 2021-02-02 _48.0U/mL
    • 2020-12-15 _30.8U/mL
  • regimen

    • 2019-09-23 ~ 2020-01-22: FOLFIRI plus bevacizumab, 8 times
    • 2021-01-13 ~ up to now : FOLFIRI plus bevacizumab

[assessment]

  • KRAS/NRAS/BRAF not found in sheets
  • 2 (MSH-6, PMS-2) of 4 MMR proteins remain intact, pembrolizumab might not be indicated.

701265877

000000

701265877

{Colon cancer}

[subj/obj]

  • (transverse) colon cancer with liver metastases, cT4aN1aM1c, stage IV s/p LPS right extended and hemicolectomy on 2020-03-26 and seedings over omentum found.

    • patho peritoneum metastases, pT4aN2aM1c, stage IVc s/p radiofrequency ablation (RFA) with switch controller (SWC) x3 on 2020-08-25.
    • patho result: poorly differentiated, EGFR (+), wildtype RAS, proficient MMR but B-Raf V600E mutation.
  • chemo (palliative) from 2020-04-27 with FOLFOXIRI (ox: self-paid; iri: insurance covered) with bevacizumab.

  • chest echography on 2021-02-23 showed right thorax pleural effusion s/p drainage of 600 cc.

  • CXR on 2021-03-09 showed right thorax small pleural effusion.

  • CEA:

    • 1.85ng/mL(2021-05-04)
    • 1.35ng/mL(2021-04-20)
    • 1.18ng/mL(2021-04-06)
    • 1.59ng/mL(2021-03-23)
    • 1.90ng/mL(2021-03-09)
  • CA199:

    • 11764U/mL(2021-05-04)
    • 4875U/mL(2021-04-20)
    • 2068U/mL(2021-04-06)
    • 1388U/mL(2021-03-23)
    • 1557U/mL(2021-03-09)

for 3 consecutive weeks then 1 week off as a cycle

Oral target therapy with Cobimetinib 20mg 1# po QD (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24~2021/0314. Oral target therapy with Dabrafenib 75mg 2# po Q12H (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C1D1) on 2021/02/24, (C1D15) on 2021/03/10, (C2D1) on 2021/03/24, (C2D15) on 2021/04/07. Oral target therapy with Mekinisc 2mg 1# po QDAC(self-paid) from 2021/03/15 (for 3 consecutive weeks then 1 week off as a cycle). Therefore, the treatment would be cetuximab plus irinotecan(C1D15) and dabrafenib and MEK inhiitor, under the recognition of T-colon cancer with metastases to liver, peritoneum and pleura, and with B-Raf mutation. This time, she was admitted for Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) on 2021/4/22.

Oral target therapy with Dabrafenib(Tafinlar) 75mg 1# po BID(self-carried) from 2021/02/24 Oral target therapy with Mekinisc 2mg 1# po QDAC(self pay) from 2021/03/15. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) from on 2021/04/23

701273749

000000

{colon cancer}

[objective]

  • 2021-03-06 CT, abdomen: A-colon tumor with pericolonic fat stranding and enlarge lymphnode.
  • 2021-03-07 laparoscopic right hemicolectomy for A-colon adenocarcinoma with obstruction, patho:
    • AJCC 8 staging: pT4aN2b, G3, IIIC
    • adenocarcinoma, poorly differentiated, with neuroendocrine feature.
    • tumor invades visceral peritoneum. bilateral resection margins are free.
    • mesocolonic lymph node: positive for tumor metastasis (10/14) with extranodal extension.
  • CEA
    • 2021-05-04: 1.35ng/mL
    • 2021-04-02: 1.47ng/mL
  • CA199
    • 2021-05-04: _33.17U/mL
    • 2021-04-02: 121.19U/mL
  • regimen
    • FOLFOX since 2021-04-06

[assessment]

  • dMMR/MSI-H, KRAS/NRAS/BRAF lab data not found in sheets.
  • based on the short trend of CEA and CA199, we might consider the condition is relatively stable.
  • for ‘T4, N1-2’ or ‘T any, N2’ (high-risk stage III) stage which includes the patient, the preferred regimen as first-line adjuvant treatment could be:
    • CAPEOX 3-6 months or
    • FOLFOX 6 months,
    • other treatment options for this stage include:
      • Capecitabine 6 months or
      • 5-FU 6 months
  • current regimen is the standard startup treatment without issue.

[suggestion]

  • have KRAS, NRAS, and BRAF mutation testing, microsatellite instability or mismatch repair testing done, even HER2, NTRK testing if possible.

701277089

000000

{}

[initial presentation]

[definite diagnosis]

  • 2021-04-20 patho, pleural/pericardial biopsy:
    • skeletal muscle fibers and fibroadipose tissue with mild fibrosis and chronic inflammatory cell infiltration.
    • IHC scant atypical cells: CK(+), CK7(+), CK20(-), TTF-1(-), Calretinin(-), p63(-), and CD56(-).
    • The PAS and AFB special stains are negative.
  • 2021-07-06 patho, bronchus biopsy:
    • alveolar lung tissue with interstitial fibrosis and infiltration of mucinous glandular cells.
    • IHC stains: CK(+), CK7(+), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
    • should check pancreas, billiary tract, stomach and else for tumor origin.
  • 2021-07-12 patho, stomach biopsy:
    • gastric tissue infiltrated by neoplastic mucinous glands and signet ring cells.
    • IHC stains: CK(+) and Her-2/neu (Ab)(-).

[disease extent]

  • still working out

[Summary]

This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM Parapneumonic effusion, right This time, she has suffered from dyspnea for weeks. Since the symptom exacerbation recent days. She was then brought to our ER for further help. At ER, rapid screeing of COVID19 revealed negative finding. CXR showed bilateral consolidation and pleural effusions, cardiomegaly. Lab exam revealed elevated CRP. Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.

Bilateral pneumonia Bilateral pleural effusion r/o COVID -19 infection

=> Abx with Brosym => Oxygen supplement => Oral radi-K => Diuretic for bilateral plerual effusion => Transfer to CM ward if PCR negative

==============================

This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM 3: Parapneumonic effusion, right.Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.After admission. antiboitc with Brosym for pneumonia and fiuretic for bilateral plerual effusion were given. RT-PCR of COVID-19 revealed negative finding. The patient might transfer to chest ward for further management on 2021/06/29.

After CM ward, she has been orthopnea and dyspnea was noted, well explained present condition and treatment plan to the patient and her husband, emergency arrange cardiac echo and chest echo for right lung mass, pericardial effusion and bilateral pleural effusion for evaluation. Cardiac echo and chest echo was done and smoothly on 06/30, cardiac echo showed moderate amount pericardial effusion, No RV compression sign, No tamponade, No pericardial constriction at present, recommended to consult with cardiac surgery for P.P. window. Chest echo report showed Left side massive amount of pleural effusion, s/p thoracentesis, yield 1000cc, serosanguos fluid. Right side minimal amount of pleural effusion. She was transferre to SICU for intensive care on 6/30. We consult CVS for moderate amount pericardial effusion and P.P window surgery(Pericardiac effusion:1350cc) on 7/01. All operation procedure smoothly and return SICU for postoperation care. Weaning ventilaotr with etubated on 7/01. Under hemodynamic stable and she will be transfer to ward for care.

After transfered to Chest ward on 7/3, Tumor marker showed elevated CA-125, CA199, 7/6 CT guide biopsy was done and patho showed adenocarcinoma with TFF-1(-), abdomen CT showed ascites and multiple soft tissue nodules in the omentum, pending cytology, and lobulated pleura thickening at right anterior basl CP angle that may be tumor seeding or primary pleura tumor. brain MRI showed No brain nodule or metastasis, EGD+colonscopy was done on 7/12 showed gastric adenocarcinoma, bone scan was done on 7/13, whole body PET was done on 7/15 revealed prominent glucose hypermetabolic lesion in the right lateral aspect of the pharyngeal wall, we will consult ENT for assessment, she was transfered to hema ward on 7/16 for further assessment and management.

701365869

000000

[objective]

  • exam finding
    • 2022-04-19 Cell block - suspected malignant pleural effusion
      • SMEARS and CELLBLOCK: Many clusters of neoplastic cells present.
    • 2022-03-25 MRI - brain
      • No evidence of brain metastasis.
    • 2022-03-23 PD-L1 (SP142) Assay (Ventana) S2022-4656
      • Result:
        • Tumor cell (TC) staining assessment: TC category: TC < 1%
        • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-03-24 Tc-99m MDP whole body bone scan
      • Increased activity in the lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
    • 2022-03-21 Patho - pleural/pericardial biopsy
      • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
      • Sections show acinar glandular tumor cells infiltrating in a fibrotic stroma.
    • 2022-03-19 Chest PA/AP view
      • There are few nodular opacity projecting in right lung that may be metastases. Please correlate with CT.
      • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-03-19 MRI - pelvis
      • Soft tissue tumors in bilateral adnexa and uterus (surface region), r/o carcinomatosis. Prominent right lower abdomen soft tissue, r/o carcinomatosis (appendix origin?)
      • Prominent ascites and bowel ileus.
      • Right pleural seeding with effusion.
    • 2022-03-15 Cell block
      • SMEARS and CELLBLOCK: Many clusters of adenocarcinoma present.
      • IHC stains:
        • TTF-1(+), Napsin-A(+): favor pulmonary origin;
        • CK20(-): dis-favor GI origin;
        • GATA-3(-): dis-favor breast origin;
        • PAX-8 (-): dis-favor ovarain origin.
    • 2022-03-15 Gynecologic ultrasonography
      • Ascites(+)
      • A mass 9.2x8.9mm in uterus
    • 2022-03-12 Chest PA (erect) view
      • Consolidation and pleural effusion in right chest

The patient suffered from SOB, air hunger, cold sweat, and the cold of four limbs, the 12 lead EKG: sinus tachycardia, the heart rate from 139bpm to 58bpm, the blood oxygen drop, changed the oxygen support with NRM O2 fll, the SpO2 97%, then we can’t measure blood pressure, and the patient consciousness become drowsy and the blood oxygen drop again, under the NRM O2 full. The VS Xia talks about the patient’s condition to the family, so gave the endo inserting, on levophed and Dopamin high dose will be transferred to MICU.